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Year : 2019  |  Volume : 13  |  Issue : 3  |  Page : 257-258

Modified E-C technique for edentulous geriatric patients

Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Correspondence Address:
Dr. Narender Kaloria
Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_767_18

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Date of Web Publication26-Jun-2019

How to cite this article:
Bansal R, Kaloria N, Bhatia P, Sharma A. Modified E-C technique for edentulous geriatric patients. Saudi J Anaesth 2019;13:257-8

How to cite this URL:
Bansal R, Kaloria N, Bhatia P, Sharma A. Modified E-C technique for edentulous geriatric patients. Saudi J Anaesth [serial online] 2019 [cited 2019 Dec 12];13:257-8. Available from:


Difficult bag and mask ventilation (BMV) may lead to serious complications which can be prevented and managed with prior anticipation.[1] Here, we report the case of an 81-year-old geriatric patient with difficult mask ventilation scheduled for microdiscectomy for L4–L5 disc prolapse. Following application of standard ASA monitoring, the patient was pre-oxygenated for 3 min and injection fentanyl 100 μg was given for intraoperative analgesia. General anesthesia was commenced by administering injection propofol 80 mg intravenously. As the patient was edentulous with no pad of fat in cheeks, gauze pieces were placed around the cheeks. BMV was started with E-C technique but there was a significant leak. Appropriate size oropharyngeal airway was inserted along with head tilt and chin lift maneuver, but we were unable to ventilate again. Then, two-hand E-C technique was used, but still there was a leak which was noticed from the sides of the nose. Hence, we modified the two-hand E-C technique by applying both thumbs to the sides of the nose instead of over the nose, and the position of the other fingers remained the same [Figure 1]. With this modification, we were able to bag and mask ventilate the patient. Subsequently, injection rocuronium 40 mg was given intravenously and the patient was intubated with 8.5 mm ID endotracheal tube.
Figure 1: The modified E-C technique by applying both thumbs on the side of nose while all other finger position same as in E-C technique

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The factors associated with difficult facemask ventilation include presence of beard or moustache, lack of teeth (edentulism), obesity (body mass index >25), history of obstructive sleep apnea, history, and age over 55 years.[2] In the absence of teeth, there is no bone of alveolar ridge that leads to decrease distance between the nose and the mandible. Loss of buccinators muscle tone also leads to hollow cheeks causing a gap between the mask and skin.[3] Mask ventilation is very difficult in this group of patients as proper seal is not achieved. Moreover, there are chances of upper airway obstruction due to fall off the tongue.[4] Methods to overcome these problems include head tilt and chin lift or jaw thrust maneuvers, insertion of oropharyngeal and/or nasopharyngeal airway to prevent tongue fall, and selection of appropriate size mask to achieve the required seal. The placement of mask at lower lip (lower lip placement) has also been described for difficult BMV in this subset of patients. Retention of denture in place during BMV also helps in providing the seal. Placement of gauze pieces under the cheeks prevents air leak around the hollow cheeks. In addition, two-hand E-C technique is also helpful in this age group.[1] In our patient, modification of standard two-hand E-C technique helped us in eliminating the problem. We could also apply additional gauges to the sides of the nose to prevent leak, but it would be very cumbersome; moreover, it was easy to apply pressure with the thumb then to put more gauges. To conclude, the modified two-hand E-C technique of pressure on the side of nose with thumbs for BMV is advised in elderly edentulous patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Soleimanpour H, Sarahrudi K, Hadju S, Golzari SEJ. How to overcome difficult bag mask ventilation: Recent approaches. Emerg Med 2012;2:1-3.  Back to cited text no. 1
Ford MP, Arndt GA. Difficult airway: Cannot ventilate, Cannot intubate. In: Atlee JC. Complications in anesthesia. 2nd ed. Wisconsin: WB Saunders Company Ltd; 2006. p. 159-73.  Back to cited text no. 2
Golzari SE, Soleimanpour H, Mehryar H, Salarilak S, Mahmoodpoor A, Panahi JR, et al. Comparison of three methods in improving bag mask ventilation. Int J Prev Med 2014;5:489-93.  Back to cited text no. 3
Defalque RJ, Wright AJ: Who invented the “jaw thrust?” Anesthesiology 2003;99:1463-4.  Back to cited text no. 4


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