Pre-intubation ventilation device for bearded patients: prospective, randomized, crossover trial in anesthetized patients

Lilach Gavish*, Shimon Firman, Roger Andres Gomez Barrantes, Angelika Erport, Joel Shapiro, Chloe Mimouni, Dina Velitsky, Arik Eisenkraft, S. David Gertz, Reuven Pizov

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Having a beard is an independent predictor of difficult ventilation by face mask. This study evaluates the efficacy of a novel intra-oral Bag-Valve-Guedel Adaptor (BVGA) in anaesthetized bearded patients. Patients with ASA score 1–2, scheduled for elective surgery, were recruited for this prospective, crossover trial. Beard length was categorized as < 0.5 cm, 0.5–1 cm, 1–5 cm, or > 5 cm. Patients were ventilated by attending anesthesiologists using the BVGA and a facemask (both with a Guedel oral airway). End-tidal CO2 (EtCO2) and expiratory tidal volume (TV) were recorded as was the number of hands required for the procedure. The primary outcome was the difference between BVGA and Facemask. Sixty-one patients were enrolled. Of these, 38 had beards, and 23 were without beards or with beards < 0.5 cm length. In bearded patients, ventilation with the BVGA was superior to the face mask by EtCO2 and non-inferior by TV (BVGA-vs-Mask, mean [95% CI]: EtCO2 [mmHg], 33.0 [31.6, 34.3]-vs-27.2 [25.5, 28.8], p < 0.001; TV [ml∙kg−1 IBW], 8.1 [7.4, 8.9]-vs-6.9 [6.0, 7.7], p = 0.11). The BVGA was found to be superior to the face mask by EtCO2 across all beard lengths (p ≤ 0.001), but by TV only for the longest beard group (p = 0.009). After securing the BVGA, ventilation was possible without hands in 74% of the cases — clearly impossible with the facemask (p ≤ 0.001). The BVGA is more effective and more convenient than the facemask in anaesthetized bearded patients. A follow-up study is underway to test whether replacing the face mask with the BVGA will improve effectiveness and ease of pre-intubation field ventilation by less-experienced, first responders.

Original languageAmerican English
Pages (from-to)559-566
Number of pages8
JournalInternal and Emergency Medicine
Issue number2
StatePublished - Mar 2023

Bibliographical note

Publisher Copyright:
© 2023, The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).


  • Bag-mask-valve
  • Basic life support
  • Face mask
  • Intraoral airway
  • Ventilation


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