Omitting Face-Mask Ventilation Before Intubation in Low-Risk Adults
For many of us, face-mask ventilation (FMV) between induction and laryngoscopy is still the default, a practice rooted in training and habit as much as in concern about desaturation. A September 19, 2026 open-access randomized non-inferiority trial in BMC Anesthesiology asked whether skipping FMV is acceptable in carefully selected low-risk adults. The safety signal looks reassuring, although the statistics do not allow a declaration of non-inferiority.
Chang and colleagues ran a single-center RCT in low-risk adults undergoing elective thyroid surgery. One arm received FMV plus rocuronium 0.6 mg/kg; the other omitted FMV and received rocuronium 1.2 mg/kg. The primary outcome was SpO2 ≤95% from induction to the first intubation attempt, with a 2% non-inferiority margin. The trial stopped at an interim analysis after 288 patients (144 per arm) with zero desaturation events in either group (risk difference 0%, 95% CI −2.6% to 2.6%). Because the upper confidence limit crossed the 2% margin, formal non-inferiority was not established, even though no patient desaturated. Median gastric antral cross-sectional area was 3.7 cm2 in both groups. Post hoc ultrasound signals of gastric insufflation appeared only in the FMV arm (qualitative insufflation about 5.6% vs 0%; CSA increase >30% about 6.2% vs 0%).
Interpreting the findings
I read this as hypothesis-generating support for the idea that, with solid preoxygenation and a short apnea window, desaturation can be rare enough that routine gentle FMV may be optional in true low-risk airways. It is not a license to abandon FMV across the board, and the authors appropriately advise confirmation before changing practice. The population was low-risk adults having elective thyroid surgery; RSI, full-stomach patients, and difficult-airway candidates were not studied. High-dose rocuronium shortens the wait for intubating conditions when ventilation is omitted, and that design choice matters whenever one tries to generalize the result.
The gastric findings are the part I will actually carry into the room. When we do ventilate by mask, pressure and technique still matter. A small post hoc signal of insufflation confined to the FMV group is a further reminder to keep peak pressures modest and to avoid “bagging for comfort” when the stomach is the only beneficiary. For aspiration-risk patients or RSI pathways, this trial simply does not apply.
Implications for practice
In this interim-stopped RCT of low-risk elective thyroid patients, neither the FMV nor the no-FMV approach produced any SpO2 ≤95% events before the first intubation attempt, yet formal non-inferiority was not met because the confidence interval exceeded the 2% margin. Desaturation was rare with careful selection and preoxygenation. That is reassuring, but it is not permission for casual apnea in every patient, and the findings should not be generalized beyond low-risk, well-preoxygenated adults. RSI and high aspiration-risk patients remain a different problem.
Any local protocol discussion should also account for the higher rocuronium dose (1.2 mg/kg) that was paired with omitting FMV to shorten apnea before laryngoscopy. Finally, the post hoc gastric insufflation signals favored the no-FMV arm, so when I do mask-ventilate, I keep pressures judicious and my technique deliberate.
Source
- Chang HW, Kim N, Eum D, et al. Omitting face-mask ventilation before tracheal intubation in low-risk adults: a randomized non-inferiority trial. BMC Anesthesiology. Published September 19, 2026. Article (doi: 10.1186/s12871-026-04276-y)
This post is clinician commentary for educational discussion. It is not medical advice for any reader’s personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient’s circumstances.