Omitting Face-Mask Ventilation Before Intubation in Low-Risk Adults
Face-mask ventilation (FMV) between induction and laryngoscopy is still the default for many of us— partly training, partly habit, partly fear of 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; the statistics do not let us declare 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 used 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 nobody 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%).
What this changes—and what it doesn’t
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—not as a green light to drop FMV across the board. The authors are appropriately cautious: confirm before changing practice. The population was elective thyroid surgery in low-risk adults, not RSI, not full-stomach patients, and not difficult-airway candidates. High-dose rocuronium shortens the wait to intubating conditions when you omit ventilation; that design choice matters when you try to generalize.
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 only in the FMV group is another reminder to keep peak pressures modest and to avoid “bagging for comfort” when the stomach is the only thing benefiting. For aspiration-risk or RSI pathways, this trial simply does not speak.
Clinical takeaways
- In this interim-stopped RCT of low-risk elective thyroid patients, neither FMV nor no-FMV produced any SpO2 ≤95% events before first intubation attempt—but formal non-inferiority was not met because the CI exceeded the 2% margin.
- Do not generalize beyond low-risk, well-preoxygenated adults; RSI and high aspiration-risk patients remain a different problem.
- Higher-dose rocuronium (1.2 mg/kg) was paired with omitting FMV to shorten apnea to laryngoscopy—factor that into any local protocol discussion.
- Desaturation was rare here with careful selection and preoxygenation; that is reassuring, not permission for casual apnea in everyone.
- Post hoc gastric insufflation signals favored the no-FMV arm; when you do mask-ventilate, keep pressures judicious and 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.