Is it necessary to confirm mask ventilation before paralyzing?

Welcome to the Depth of Anesthesia. This is a podcast where we critically explore our clinical practices. My name is David Hao and I'm an anesthesia resident at the Massachusetts General Hospital. And my first guest on this show is Dr. Daniel Saddawi-Konefka, who is the program director at Massachusetts General Hospital. Thanks for joining us and welcome to episode one.

Hey Daniel. Hey David. How's it going? Pretty well. How are you doing?

Excellent. Very excited to be doing this. Excellent. What's our case this week? So our case today is a 72-year-old man, a history of coronary artery disease, hypertension, obesity, and diabetes who's presenting for a laparoscopic umbilical hernia repair.

He's 510 and 120 kg and you notice he has a pretty thick neck. After induction, you make sure to check mass ventilation before giving your intubating dose of rock I get it. Right there it is. Right. You're you're doing the mask ventilation before administering the rock uranium.

That's the claim That's the claim. The claim is, I guess, how would we say that? That that helps, that that's an important thing to do. It gives you useful information. It'll change your management.

It's something. It's a habit. It's something you're doing. You're doing it for some reason. It's all of those things.

So for our listeners out there, take a minute and just think about your own clinical practice or what you've seen. Yeah, the question is, uh do you agree with that claim? Uh is do you think it's important to do verify mass ventilation before paralyzing the patient? We're not gonna we're not here to talk about whether it is important or not, but let's explore the evidence that underlies uh the claim. Uh what do you think the evidence is?

This is for our listeners Uh do you think there's no evidence, but it sort of stands to reason? Do you think there's expert consensus? Maybe there are mixed trials, some show one way, some the other. Is it all correlation stuff or do you think we actually have pretty high level evidence? Causal evidence, randomized control trials.

So we asked our providers here at MGH what they think. Do they think this is a safe practice? It's the better practice. You know, it sort of split the group. If you take a look at the got the numbers here in front of me, it was it looks like it was about a third of people prefer to establish mask ventilation before.

Maybe a third of people Mm-hmm. Think that they shouldn't, and then a third of them in the middle thereabouts. Pretty evenly split. Yeah. Alright, so now let's talk about the rationale.

Why would you favor one over the other? So, David, why would you want to verify mask ventilation before paralyzing someone? What's the claim? What what how do people explain that? So one of the rationales that I've heard from those who advocate for checking mass ventilation is that by checking mass ventilation before giving a paralytic You don't burn a bridge.

You could still theoretically wake the patient up in the event that you either couldn't secure the airway or notice that mass ventilation is extremely difficult. Yeah, yeah I've I've heard some other things too. You know, some people say well I want to be able to mask them before I give the paralytic because maybe it'll change the decision that I make. Maybe I'll give them one paralytic versus another Something that's gonna kick in faster to help with my mask ventilation, so I wanna know. What are the reasons you've heard for not checking?

Oh right. So the people will say no no just paralyze right away. So I think the main rationale there is they say if you paralyze them you're gonna help your mask ventilation and you're gonna help your ability to intubate. They also say it's unlikely you're gonna be able to wake them up, so you might as well not waste time, especially if it's gonna be difficult, just dive in, just give the paralytic, it's only gonna help you do what you need to do. So those are just the claims that we've heard on either side, the rationales.

But uh if you're listening to this and you think, well, hey, hey, whoa, uh I actually don't paralyze for this reason or that reason, or I do paralyze for This reason, then just shoot us an email at depth of anesthesia at gmail. com. It's all one word, and uh we'll get it out to the other listeners. So David, I know that you actually got a little bit of data about this, about how anesthesiologists in the UK feel about this, right? The 2010 survey, can you tell us about that? So in 2010, Broomhead surveyed 136 anesthesiologists.

The results of the survey showed that 43% said that they would not check. And 57 % said that they would check. But the interesting thing is that in a hypothetical situation, most of the docs who said that they would not check would give succoline in the event that they couldn't mask. What was also pretty interesting was that trainees were significantly more likely than attendings to be checkers. But the real kicker here is that twenty of the thirty two, so about sixty three percent of those who said that they wouldn't check, actually replied that they wouldn't volunteer that information if they were asked about it in an exam.

Hold on, so just to get this straight, you're saying that nearly two-thirds of the people who said they wouldn't check Wouldn't actually say that on an exam? So so in real life they wouldn't check. They'd just paralyze, but on an exam they'd say, Yeah, I'm gonna I'm gonna check first. Yep. So Dan, what do we actually know about impossible or difficult face mass ventilation from Prospective Series?

Right, so difficult and impossible face mask ventilation don't really have consistent definitions in literature. The biggest study I know about is the 2009 one out of Michigan by uh Sachin Ketterpal. It involved around 53,000 patients. They had around 77 cases of impossible possible mask ventilation that's an incidence of about point one five percent. And you mentioned the problems with defining this.

The ASA does actually have a definition of difficult mass ventilation and they describe it as a situation in which it's not possible for the NSCC all just to provide adequate ventilation. because of one or more of the following problems. So those would include inadequate mass seal, excessive gas leak, or excessive resistance to the ingress or egress of gas Right, and I think the the problem with it is that when you actually try to operationalize that and you get well it's this is I think it's fine, there's a little bit of a poor mask, but it's not really that troubling So the the the problem there is a little bit of interoperator variability. And also, you know, uh difficult mask in one person's hands, maybe not so difficult in another person's hands.

So that that's a little bit of the the trouble we see with it. Alright Dan, I think it's time. Let's get into these claims. So for the first claim, which is that checking mass ventilation before giving a paralytic is beneficial. What people will often say is that if mass ventilation is inadequate, you still have the opportunity to wake the patient up before they desat.

So what do we know about how long it actually takes to wake someone up after you've induced them? Right, so the idea is how long does it take after you induce for them to desaturate to a point of no return? Yeah, exactly. Well, in nineteen eighty-four Drummond did this study. Uh this was published in the British Journal of Anesthesia.

He took twenty patients and had them breathe air and then induced them and saw where were they after a minute And from breathing on room air to after a minute, the m the mean saturation was eighty-five point five. Mm-hmm. So that's already a little too low. Yeah, it's pretty low. But I don't know that that totally answers the question.

Because nowadays we don't induce people on room air, right? We preoxygenate them. Exactly. The basic idea behind that, the rationale, if you will, is you know you got about two liters of functional residual capacity if you bring that up to ninety percent oxygen. 90% of 2 liters is about 1.8 liters of oxygen. So if you assume someone consumes, I don't know, 250 cc's of oxygen per minute, That's about seven minutes before they were take.

Yeah, give or take. That's a seven extra minutes before they desaturate there. Right, so uh I don't know how to pronounce the name J-E-N-S-E-G-C, maybe? Nice. Um published in Anesthesia and Analgesia.

So they took uh healthy patients that were undergoing elective surgical procedures And they would induce them, intubate them, and wait to see how long it took for them to desaturate. That's an amazing study. Yeah, totally. What they they and they did actually pretty good pre-oxygenation. They went to end title nitrogen concentrations of less than five percent.

So this is mostly oxygen. And for folks with normal weights, the time that it took till their sets dropped below 90% was around 360 seconds or six minutes. Six minutes. Yeah Did they ever figure out what about in the situation of morbid obesity? You've seen the study, I think, right?

So yeah, they they had another group that was a morbidly obese group. Um and uh how did they define that? Is a BMI of over I'm sorry, it wasn't a BMI definition. It was forty-five point five kilos over ideal body weight. That's what they defined as morbid obesity in the study.

And for that group, it was 163 seconds, right? That's 2.7 minutes. And I'm pretty sure though just for for this is important, these patients were all supine. Right. Right.

And so if you increase, if you go back up, then your uh FRC increases. You should get a little bit more time. Right, and this has been studied. Right. So this is a study by Dixon.

This is published in 2005 in anesthesiology, and they took morbidly obase patients uh and they randomized them. to either supine inductions or 25 degrees headbed elevation inductions. And same sort of thing. They waited for them to desaturate. They used a cutoff of 92% sat. So what do they actually find?

Right, so similar to the Gen C article uh in the Supine group, uh to get to uh ninety-two percent was our hundred and fifty-five seconds. Remember it was 160 something, the Gen C article. Pretty close. Yeah. For the group though that was twenty five degrees head of bed elevated, two hundred and one seconds.

Okay. Yeah Yeah, this is pretty in line with our general understanding that in the situation of decreased relative FRC like pregnancy, obesity, intraabdominal hypertension, they all begin with a low reserve Yeah, and and not just the lower zer, but there are also s situations where you might have increased oxygen utilization Exactly, so uh hypermetabolic conditions like critical illness, pregnancy, pediatric population, all of them are gonna have a higher level of oxygen consumption per kilogram weight. Right, so they'll desaturate faster So I want to tell you about one other study, and this study was done in 2014, published in the International Journal of Clinical and Experimental Medicine. And what these folks did was they they weren't looking at desaturation, but they were more looking at like, well, how long until they breathe, right?

That's a little more functional uh relevant to what we're so what they did was they they took a cohort of patients 27, right? Uh I believe all elective gyne cases. Yeah, that's right. It was twenty-seven patients. Uh and these are by the way, these weren't heavy patients who's I think the the average weight was around fifty-eight kilos And they gave them uh an induction.

It was two per kilo of propofol, one mic per kilo of REMI, and 0.6 per kilo of succinylcholine. And they induced them and intubated them, no ventilation during the whole thing, and they waited until they woke up. So how do they decide if someone woke up? They just look in and as soon as the person opened their eyes or how how was that figured out? Right.

So I I think what they did was they actually after the tube went in, every ten seconds they would pat him on the shoulder and call their name. Are you serious? Totally serious. And and they waited until uh either eye opening or spontaneous breathing or something like that, and then there's someone else there who is ready to just uh induce the patient. So how long did it actually take?

So around 245 seconds, plus or minus a minute. So three to five minutes. Three to five minutes. Okay. So this just to summarize on on this side of the claim, if you're gonna wake folks up, you wanna be adequately preoxygenated, maybe get their back ahead of bed up.

Um and count on three to five minutes. So you want to plan whatever you induce them with, uh to to be off by then. Right. So Dan, what do you think? Is this possible?

Is this plausible? And have you seen people do it in real life? Oh definitely. Definitely. In fact, there's a that that Kheterpal series we were talking about.

Yeah. Uh let's take another look at that So this was the observational study, right? The one they did over four years, and it was more than fifty thousand mass ventilation attempts, right? Right, right. And uh what I what I do want to point out uh is that Of these 50,000, there were two patients who got woken up.

Now you gotta bear in mind this is one institution, so Uh it could be other institutions wake people up a lot more. This might be a culturally uh motivated thing as opposed to uh anything saying whether or not it's possible, but But in this series we do see that people were woken up when they couldn't be intubated or uh mask ventilated. What do we know about those folks, the the two that got woken up? Unfortunately, I don't know a whole heck of a lot about them. I don't recall them being described in the paper.

So I can't tell you whether these were super high-risk folks or what the inductions were Or if they used neuromuscular blockade with them. I can't recall. Gotcha. So we know in this study two got woken up and what happened to all the other people who were impossible mass ventilation Right, so of those, uh fifty-eight were intubated normally, fifteen were intubated with some alternative intubation techniques, and two got surgical airways. Gotcha, so Let's say in the 77 impossible mass ventilation, about four were quote unquote couldn't intubate folks.

Right. The two that got open up and the two that got the surgical airways, right. So the other aspect of this is that those who advocate for checking mass ventilation will sometimes say that depending on whether or not mass ventilation is a achievable, they'll make a decision about their subsequent steps in terms of either giving a short or long acting uh muscle paralytic. Do you think that that's valid? So I think what you're saying is that they check to see if they can mask.

If they can't, they're gonna give something that's on real quick and off real quick. And if they can, then they'll just give whatever and it's fine. That's exactly right. So I think one of the premises there is that uh if you want it to come off pretty quickly, you'd give succinylcholine. Whereas if oh you know the mask is fine, doesn't really matter, we're gonna be fine, I can give something like cisatracurium or rocuronium and That may have been historically very important, but maybe it's not as important in the era of Psygamedex?

I think that's a really valid point, and there's actually a study that was done in and published in anesthesiology uh talking about reversal of neuromuscular blockade with sucamidex and what they did was they looked at about a hundred and fifty um ASA 1 to 2 surgical patients and They randomized these patients to either getting uh neuromuscular blockade with 1.2 milligrams per keg of rock or 1 MG per keg of sucks. They induced with propofol and an opiate which I believe was fentanyl, and they looked for return of neuromuscular function and what they did was the primary endpoint was recovery of the first train of four twitch So just to clarify, David, uh recovery of the first twitch, they must have had some baseline value and then they said, well, it's when that first twitch is some percent of the baseline value.

That's right. So they got a baseline value and they waited to see recovery of the T1 to 10% of that baseline value. So what'd they find? So what they found was that the mean time to recovery of T one to ten percent was significantly faster in the rock and sugaminix group at four point four minutes, compared with the succinylcholine group, which was seven point one minutes. They also did a recovery of T1 to 90% and that was also faster, so 6.2 with the Roxagamnex group and 10.9 with the Sux group.

So just just to make sure I'm understanding this right, this is not like we're ready to extubate people. No, absolutely not. Right. It's like the T1 at ten percent of the baseline, we're not ready to extubate them. Even T one at ninety percent This is not the T four to T1 ratio.

This is just percent of baseline, is that right? Exactly. And what this suggests and and what I think it suggests is that these values are probably the lower end. So it's absolutely not extubatable criteria, but you could use this as a metric of saying it would take at least this long for you to even consider the patient having return of neuromuscular function to a to a range where you could extubate. And in the case of what we're talking about, it's not necessarily excavate, but I guess uh exchange meaningful gas, right?

Because it we just want to keep people alive. Exactly. All right. So if I if I'm taking your point correctly, what you're saying is that this paper shows that if you give rock followed by su gamma dex, which is given three minutes after the rock that you'll reverse it at least as fast as SUX and L. C. oline.

Actually I would even take it a step further. This study pretty conclusively demonstrated that the Roxugamidex group actually recovered faster than SUX and And keep in mind that the Sagamedex was given three minutes after rock administration, and what I believe the authors were trying to accomplish, and what they mentioned, was that this was an approximation of about three minutes of an attempt at intubation. Alright, so punchline based on that article is that uh if you have Sukamadex, you could probably still go with rock and not use that as your argument for why you check. I think that's fair. There's actually one more rationale that I've heard for checking and and this was brought up in our grand round session.

One of the docs said that Checking is in fact a data point. It will help guide future anesthetics and for docs looking at this chart they would be able to either see that this patient was maskable or not and that could probably help guide future management. What do you think? I think there's some merit there, right? If you you don't know if they're maskable without paralytic. uh unless you try to mask them without paralytic.

The question is what is the value of that information compared to uh any support of the alternative claim, which is that giving paralytic early is is better for other reasons. Mm-hmm. But I don't actually know any data on the value of that information. That is just one of those things that Um I think actually has some merit to it. There's some merit to that claim.

Alright, so let's actually switch to that other claim then the claim that it's better to just give the paralytic upfront. So remind us, David, what are the reasons why do people say that we should just give the paralytic upfront? So some of the rationales that I've heard is that by giving a paralytic early, you're optimizing your conditions for not only intubating, but also for mask ventilation. And By optimizing those two aspects of your airway management, that will likely outweigh any sort of purported benefits of checking mass ventilation first. So we've got to look at that.

We've got to figure out, is there data to support the claim that giving the paralytic is going to help your mask ventilation, say? So, Dan, what do we know about paralytics and mass ventilation? And does giving a paralytic actually help your mass ventilation So it seems like on a population level the answer is yes. I'll tell you about a few of the studies. So there's one from 2011 by uh Warders.

They took 90 patients, they induced them, and then they had a blinded anesthesiologist who was grading the difficulty of mask ventilation. And this is sort of a homegrown scale, uh that's what they called it the water scale, the pro prime first author's name. Um and uh what they did was they randomized these 90 patients to either getting normal saline or rocuronium, and then this blinded anesthesiologist two minutes later would assess the difficulty of mask ventilation using that water scale. Gotcha. So what did they find?

Well they found that rocuronium improved ventilation scores. After giving rocuronium compared to the baseline values, the difficulty of mask ventilation decreased. Interestingly, they also did a subgroup of patients who had an initially more difficult mass genulation, and in those patients, rocuronium still improved, actually more significantly. the uh difficulty, the ease of uh mask renovation. That's an important thing because uh some folks say that the harder to mask people, maybe that's a special type of group of people who parallel like might might hurt them more because of soft tissue is getting in the way and so forth. Uh in another important side note on this The group that got saline compared to before and after the saline, there was no difference in this score Which is which is important because even though the anesthetist is blind, they know they're studying something about this.

So there might be demand characteristics. They might think, oh, I'm supposed to say it got better. But no no difference in the sailing group. only the rocuronium group and they got significantly better. So that bodes well for the relevance of this data. Right, right.

But what it doesn't tell us is, well, okay, so it was mat it was graded as better. But objectively, how much more should I expect in terms of C C's per title volume or how how clinically relevant is this? Yeah, it's difficult, but if I can still squeak some air by and they're still alive, why does it matter? And you did find a study that actually quantified title volumes, right? Right.

There um there there are there's more than one. I'll talk about two. Okay. So the first study was done in 2014 by Sachteva and colleagues, and what they did was they took 125 patients who were getting induced. And they put them on pressure control with 15 centimeters of water.

I think it was two-handed uh mask. And They followed tidal volumes as the neuromuscular blockades set in. Each of these folks got 0.6 per kilo of rocuronium, so a r uh not an RSI dose. Standard intubating dose. Yep.

Yeah And their primary thing was pre-post initial title volumes. These are expiratory title volumes that were captured, compared with two minutes after the Neuromuscoda blockade was given And what they found was an increase in tidal volume, uh modest, 61cc on average. Uh a couple important caveats. One is if you're if you're breathing for someone twelve times a minute Sixty times twelve, what is that? Seven twenty.

Right, seven hundred and twenty C 's if that's mostly oxygen uh even if it's some modest amount of oxygen, that's more than enough to sort of maintain vital function. Uh the other thing that's important is though that was the mean increase Um that may not be the case for all patients, but of these hundred and twenty-five, there were no patients who had a decrease in title volume. Right. So what that's it is suggesting to us is that by giving a paralytic at worst nothing happens in terms of your mass ventilation. Yeah, at least for the people who are included in this particular study, which may not include everyone.

Sure. You know, and I think look in a exclusion criteria were or types of patients that are included is is important. Like we were saying earlier, the type of patient you are taking care of in front of you might meet the exclusion criteria for all the trials you're talking about. Oh absolutely So interestingly, as we were in the process of recording this podcast, another randomized control trial came out, right? Comparing early and late administration of rock before and after checking mass ventilation.

Right, so this is by Min and colleagues published in Anesthesia and Analgesia. So this is prospective, it's a double blind uh randomized control trial, uh done at a hospital, I believe, in Korea. And what they did was they took 114 patients and they randomized them to receive either IV rock before checking or after checking. And so again, it's 0.6 per kilo that they gave a rocuronium. And they compared the average tidal volume delivered by mask ventilation at ten seconds, twenty seconds, thirty, forty, fifty, and sixty seconds after apnea.

Okay. And they compare them between the two groups. Right. And what they found was consistent with the such Dava paper. They found higher tidal volumes in the one group versus the other.

The difference was 552 cc's on average in the early rock compared with 393 cc 's uh on average in the in the late administration. Either of those are totally fine, right? The other thing they found though, which was which is not their primary outcome, but there was a s statistically significant difference, was that the folks who got early rock eronium versus late had earlier tracheal intubations So that begs the question, when were they allowed to intubate these patients? Right, so it was at a train of floor count of zero. Gotcha.

So it kind of makes sense. It was 116 seconds versus 195 seconds. So on the basis of these two studies, can we pretty conclusively say that mass ventilation is probably aided by your paralytic and at worst it doesn't do anything Y you know, I don't I don't know if if we can say it conclusively. So I'll I'll give you just one example here. In this in this Min study, some of the exclusion criteria here were predictors of difficult airway, such as and I'll read it here from the paper BMI greater than thirty-five, mull and potty three or four, mass or radiation changes in the neck, limitations in mouth opening, neck extension or jaw protrusion, history of snoring or sleep apnea So so maybe, but but gosh, there's a lot of worrisome exclusion criteria from this paper that we were just talking about.

It's it seems like it helps. We don't have a lot of data to suggest that it hurts, but your question, can we conclusively do it based on these two papers that we just talked about? I don't think so. Okay, so there is one paper though which I found to be really interesting. They weren't looking at should we paralyze early or late.

What they were actually doing was prospectively uh trying to validate this difficult airway algorithm that they had uh developed and uh so I want to talk a little bit about it because i i the what they do with paralytic is interesting It was published in anesthesiology in 2011. This is a paper by, I'm gonna put you the name, I'm sorry, uh Amathia, maybe, A-M-A-T-H-I-E-U. And it was two-year prospective validation in patients getting elective abdominal gamacologic and thyroid surgery. So all in all, this is over 12,000 patients that they looked at. So what they were doing again is is trying to prospectively validate this difficult airway algorithm.

So let me tell you about the algorithm. So they excluded anyone who was an aspiration risk. Anyone who they thought was going to be an impossible intubation, they intubated awake. What were their criteria for impossible intubation? So they said if their mouth opening was less than two and a half centimeters, if they had a severe fixed cervical flexion, um or if they had a history of a previous impossible intubation.

Okay, so for those patients they Got what fiber optic or yep away fiber optic intubation. Just to cut forward a little bit, um, of the 12,000 over 12,000 patients, that was four patients. Okay. So and and uh so excluding the aspiration ones, only four got the away fiber out. So everyone else went to the difficult or sorry, to the to the next step on the algorithm.

So the next step was uh the question was, do we think they're going to be a difficult intubation And and what they defined that as was three or more predictors of difficult intubation. And here's the catch. If they thought they were going to be difficult, then they gave them succincholine immediately on induction. So they absolutely just went for it. Right.

Right. And this so these are clearly people who are in the camp of just give the paralytic right away. I don't want to wait because I need to help my intubating conditions, so on and so forth Um and then everybody else, they just induced normally, and then they tried to mask them to actually get a little bit of information. If they found the mask was difficult Then they gave succinylcholine right away. Gotcha.

So any sign of trouble they would give sucks. Yeah, so if there's predictors of difficult, sucks. If no predictors, but the mask was kind of troubling, still sucks. Right. Everybody else, some alternative paralytic.

Non-depolarizing So let me tell you what they found. So like I said, four got a wake fiber optics, one had a history of real tough intubation, one had a uh distorted trachea because of a mass, and two had fixed cervical flexions with limited mouth opening. Of the remaining 12,221, 98% were successfully intubated with a MAC blade. right, which leaves uh two hundred and thirty-six patients. Of those uh eighty-eight percent of them, two hundred and seven, were intubated with a backblade plus a gum elastic bougie. Gotcha.

So that leaves what uh 29 patients. So 27 of those, so this is now 93% of the remaining ones, were intubated with a video laryngoscope. And that leaves two patients who were all successful who were both uh successfully managed with uh an LMA. Uh importantly in this study No one died. Um 87 patients total, so this is 0.7 %, did have a SAT reading of below 90%.

Um 17 uh patients, this is overall 0.1 %, had a SAT reading of less than 80%. And the lowest SAT reading uh across the study was 68 %. Um, notably uh no aspirations uh during this, although they did uh exclude from the get-go people who were aspirational risk. So Dan, what do you think is the big takeaway? Well, you know, it wasn't the point of their study, but one thing to take away from this is hey, here's over twelve thousand patients that were managed. without checking when it ostensibly would matter most and the people who were really difficult and complications were minimal.

Just a little bit of desaturation, but nothing to anything That's concerning. So this seems like it's pretty good data in support of not checking mass ventilation. I guess you you could take it that way, obviously with some caveats. So um first of all, this is this is not what they were intending to study, and there is no compare group We have we have no data from from this study to say well what what would have happened if they didn't use the paralytic right away. Right.

Who knows? Maybe everything also would have gone fine. Exactly. And what about the generalizability of this data? Right, so that's a perfect question.

There are a bunch of patients who were not included in this study. So It only included abdominal, gynecologic, and thyroid surgery patients. So no obstetric patients. No this hospital doesn't take care of patients with uh head and neck cancer, so none of those were in there And none of the other things, uh cardiac, uh thoracic, if there are reasons that those patients might be different, we uh to conclude anything about that population set would be extrapolation of the data that's here. Now another thing is that the people managing the airways were were fifteen senior anesthesiologists, sort of seasoned airway experts.

So I don't know if this management algorithm, if this approach, necessarily generalizes to folks who are less expert in airway. That all said, this is a dataset of over 12,000 patients that includes a lot of difficult airway type patients that we would commonly see in practice. So I don't think we can ignore it totally. And I think it would support, at least in part, the claim that uh At the very least, if you give paralytic early on, maybe not so bad. Yeah, I think that's a pretty fair and balanced interpretation of this data.

Thanks. So now what? Now we revisit our questions. Same same questions we'll ask every one of these episodes. What's your level of belief in the claim?

And what is the evidence that you think underlies your belief? So, what are the questions for this particular episode? So, what is your level of agreement with the claim that you should establish mass ventilation before paralyzing? And what's the level of evidence for what you believe? Excellent.

We certainly hope you had a lot of fun listening to this. We had a lot of fun making it. We hope that uh it gets you to think critically a little bit about your practice or the practice that you see. And that you stay thirsty, keep reading papers, keep drawing your own conclusions. Thanks, Dan.

Thanks, David If you enjoyed the show today, leave us a five-star review on iTunes. This will help get the podcast out to other listeners, and each podcast is also posted on depth of anesthesia. com We'll have up-to-date show notes and references on that website and you can always drop a comment and yeah we'll try we'll do our best to reach out to you If you didn't enjoy this podcast, make sure to give us a one-star on iTunes and so forth, just to save the public from it, you know, to steer them away. Please don't do that. To our listeners, thanks for joining us this week. And a shout out to the MGH Department of Anesthesia, Critical Care and Pain Medicine for their continued support.

And a special shout out to Dr. Stephen Campbell, who is one of our CA2 residents. He composes exclusively for our podcast and gonna leave you in his capable hands.