I read with interest the article by Racine et al .1that demonstrated that repositioning of the caudal end of the mask above the lower lip resulted in a reduced air leak in edentulous patients. Another effective technique for a problematic situation is always welcome. However, my concern, based on personal experience and figure 2 from the study by Racine et al ., is that, in some patients, pressure may be applied to the eye, risking ocular damage. I have been around situations in which the facemask was moved cephalad to obtain a better seal. On occasion, the facemask would then be in direct contact with the closed eyelid. In addition, I am confused by their statement that the cephalad end of the mask stayed in the same location for both positions. First, a comparison of their figure 1 with their figure 2 would suggest otherwise. Second, how can one end of the facemask be moved without moving the other end?

Because of the potential risk of ocular damage, I would try other methods first. As an alternative, head straps can be used to buttress the cheeks against the facemask in a standard position. There was no mention of using head straps during their study or in any of the background studies discussed. I am unaware of any data that evaluate the efficacy of head strap use in this situation. I have been highly successful in dealing with air leaks in edentulous and bearded patients by inserting an oral airway and using head straps. In a few patients, a variable-sized leak may remain, but it is rare to not be able to achieve adequate ventilation. This avoids the risk of ocular trauma. Although not always necessary for ventilation, the oral airway tends to lessen the magnitude of the positive pressure required for adequate ventilation, thus reducing the tendency for an air leak via  the facemask–patient interface. By using head straps, usually only one person is needed to manage such an airway. Head straps may be particularly helpful for those practitioners who have small hands, short fingers, or limited hand–finger strength by virtue of fatigue or constitution. A formal evaluation of head strap efficacy would be welcomed.

Albert Einstein Medical Center, Philadelphia, Pennsylvania. rothj@einstein.edu

Racine SX, Solis A, Hamou NA, Letoumelin P, Hepner DL, Beloucif S, Baillard C: Face mask ventilation in edentulous patients: A comparison of mandibular groove and lower lip placement. Anesthesiology 2010; 112:1190–3