A patient with a (bushy) beard can present a challenge for several reasons:
- Bag-mask ventilation (BMV) might be challenging because of the difficulty of achieving a good seal betwen the mask and the facial hair.
- The beard might obscure adverse facial features during the preoperative airway assessment. There is therefore a higher chance of encountering an unanticipated difficult airway.
- Facial hair might lead to some challenges in securing the ET tube. Since this is only a potential problem after successful intubation, this is the least dangerous problem for the patient.
Patients might take varying degrees of pride in their facial hair, for esthetic or even religious reasons. If you suspect that airway management might be difficult, especially if for reaons other than presence of a beard, there is no harm in politely asking if the patient would consider shaving or at least trimming the beard.
How to bag-mask ventilate the patient with a beard
This is basically all about either achieving a seal between the anesthetic facemask and the bearr or bypassing the beard seal problem through other ways of giving positive pressure bag ventilation.
1. The gel method
Applying copious amounts of lubricating gel/ jelly to the portion of the beard which will be in contact with the facemask and to the cuff of the mask is often sufficient to achieve an adequate seal for BMV.
2. The occlusive dressing method
This is a moderately effective and not particularly elegant method of facilitating BMV in the patient with a beard. Size matters here, so chose the biggest dressing available. Cut a hole in the center of the dressing to accommodate the patient's nose. Remember that during BMV gas will flow through the nasal passage rather than the mouth, which will be occluded by your basic airway maneuvers (unless you have inserted an oral airway in which case the opening in the dressing must include the mouth as well).
3. The pediatric facemask method
The goal here is to create a mask seal just around the nose (hence a smaller/ pediatric-size facemask is needed) and occlude the mouth with basic airway maneuvers, i.e. chin-lift and head-tilt. This method will not work with an oral airway in-situ as this will allow air to escape through the mouth when you start BMV. Naturally, a nasopharyngeal airway might increase the success rate of this method.
This method can of course be combined with the 'gel' approach (see above).
4. The 'nasopharyngeal airway with tube connector' method
5. The 'early' supraglottic airway/ laryngeal mask
This is not so much a technique as a way of bypassing potentially difficult BMV and moving on early to inserting a supraglottic airway/ laryngeal mask to oxygenate the patient with a beard. A supraglottic airway is also your first rescue technique in any case of difficult or failed BMV (see difficult airway algorithms).
How to secure the ET tube
Using adhesive tape to secure the ET tube is clearly going to be difficult in the bearded patient.
Viable alternative techniques are the described in our section on 'securing the endotracheal tube'.