Preamble: Movember
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Movember is an annual event involving growing a mustache during November to raise awareness and funds to support men's health issues including prostate cancer. To support Movember, this post is about mustaches… and critical care, of course.
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Introduction with a Case
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Once upon a time at Genius General Hospital, there was a patient who needed to be intubated. He was edentulous and had a Mallampati I airway, with wide mobility of his jaw and neck. I was quite confident that we could intubate him without difficulty (enormous mistake: see Murphy's Laws of Airway Management #3 below).
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We proceeded with rapid sequence intubation but for some inexplicable reason the pulmonary fellow was unable to get a view. Eventually I took a look, and realized the problem: the patient's handlebar mustache was blocking the line of sight to the larynx (figure below). With some difficulty I was able to get enough of a view to place the endotracheal tube, and the patient was intubated without complication. However, it was striking how his mustache made what should have been an extremely easy procedure challenging.
Difficult laryngoscopy due to a protruding mustache
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Although not featured prominently in the literature, this has been reported before. One reported solution is to force the mustache flat using adhesive tape (Dalgleish 2000). As can be seen in the above figure, the mustache must be pushed closer to the patient's face and out of the line-of-sight of the laryngoscopist.
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Difficult mask ventilation
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It is more widely known that facial hair may impair mask seal during mask ventilation. There are a variety of solutions to this problem including inserting the mask between the lower lip and teeth, encircling the patient's entire head in plastic wrap multiple times and cutting a hole for the mouth, or placing a tegaderm dressing or defibrillator pad over the patient's face with a hole cut for the mouth (figure below; Dalgleish 2000, Crooke 1999). Despite such solutions, a beard has been shown to be an independent predictor of impossible mask ventilation despite attempts by multiple anesthesiologists (Kheterpal 2009; table below).
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A transparent Tegaderm dressing cover may be placed over the beard to improve mask seal. A hole is cut for the mouth, but the dressing should be allowed to adhere to the lips. Image from Johnson 1999. |
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Difficulty securing the endotracheal tube
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Despite our best efforts, self-extubation and accidental extubation happen. Facial hair makes it harder to secure the endotracheal tube, likely increasing the risk of unintended extubation (Kamalipour 2003). This is a very dangerous situation with consequences including cardiac arrest, hypoxemia, and aspiration pneumonia (Bhattacharya 2007).
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Multiple dimensions of difficulty
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As illustrated in the Vortex airway algorithm above, there are essentially three methods to safely support a patient's oxygenation and ventilation: tracheal intubation, mask ventilation, and a laryngeal mask airway. Prominent facial hair may impair two of these methods, potentially moving the patient closer toward requiring a surgical airway. Any risk factor which can complicate multiple methods of airway management (e.g., obesity) deserves respect.
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Facial hair management plan
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I have a confession to make. When faced with a patient with prominent facial hair, I have a low threshold to remove it prior to intubation with electronic clippers (which can easily be done in a few minutes while preparing for intubation). This may be an unnecessarily aggressive sledgehammer-style approach, but for patients being intubated in the ICU the risk of airway complications or self-extubation outweighs cosmetics. This approach has been recommended previously (Bhattacharya 2007; Wilson 1998; Moore 1999). Some cultures may avoid shaving (i.e., Islam, Amish, orthodox Judaism) so it should ideally be done with consent if there is any question regarding this.
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As discussed above, there are a variety of approaches to managing the challenges of facial hair. For example, it might make sense to go directly to a LMA in between intubation attempts, rather than attempt mask ventilation (Alexander 1999). Regardless of your preferred approach, it is crucial to recognize the issue and develop a plan prior to laryngoscopy.
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Take-home points
- A protuberant mustache may block your line-of-sight to the vocal cords when performing direct laryngoscopy.
- A beard may render mask ventilation challenging.
- Prominent facial hair can make it difficult to secure the endotracheal tube, possibly increasing risk of self-extubation.
- Quickly removing facial hair with electronic clippers before intubation is one approach to improve the safety of emergency airway management.
- Once the patient has recovered from ICU and left the hospital, he may re-grow his facial hair next Movember to increase awareness of Men's health.
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Image credits:
Laryngoscopy line-of-sight: http://bja.oxfordjournals.org/content/89/5/772/F1.expansion
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By reading your article, i have come many solutions about facial hair, airway management, and Movember. You have described that completely ease solution for the people. When people will read full article, he/she will get the brief description about it. Thanks for sharing nice info. Keep it up. See you later.
Nice post
I've been taught that another reason facial hair is associated with more difficult intubating conditions is that men with small chins (resulting in a short thyro-mental distance) are more apt to grow a beard because it gives the appearance of a more prominent jaw. Never trust a man with a beard; he's always hiding something…
Thank you for information, as this is one of the first articles that have even some statistics in it when it comes to shaving 🙂 Cheers from Estonia