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Year : 2013  |  Volume : 29  |  Issue : 3  |  Page : 407-408

Acute shoulder pain for holding the face mask: A complication of mask ventilation

Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication27-Aug-2013

Correspondence Address:
Mihir P Pandia
Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-9185.117061

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How to cite this article:
Kumar A, Pandia MP, Dash HH. Acute shoulder pain for holding the face mask: A complication of mask ventilation. J Anaesthesiol Clin Pharmacol 2013;29:407-8

How to cite this URL:
Kumar A, Pandia MP, Dash HH. Acute shoulder pain for holding the face mask: A complication of mask ventilation. J Anaesthesiol Clin Pharmacol [serial online] 2013 [cited 2022 Sep 28];29:407-8. Available from:


We describe a situation where both the anesthesiologists developed painful shoulders. A 38-years-old, 50 kg female with diagnosis of craniovertebral junction anomaly and myelopathy developed respiratory distress. Transoral odontoidectomy and posterior fixation was done the day before. She refused to undergo awake fiberoptic intubation. In anticipation of difficult intubation, fiberoptic intubation under sedation and the possibility of emergency tracheostomy was explained to the patient. Since mask ventilation was possible after giving propofol, rocuronium was given to facilitate tracheal intubation. Fiberoptic intubation was tried for four attempts but was abandoned because of mild oral bleeding. An attempt of direct laryngoscopy revealed a Cormack-Lehane grade 4 view. Patient was manually ventilated through a size 3 anatomical mask and a Bain circuit. Ventilation gradually became difficult. In spite of the best fitting mask, jaw thrust, use of both hands for holding the mask and the use of a Guedel airway, ventilation was difficult and needed lot of efforts. SpO 2 was maintained above 90% throughout mask ventilation. Laryngeal mask airway insertion was unsuccessful even after multiple attempts. Patient was ventilated with the face mask till an emergency tracheostomy was completed expeditiously. The second author held the mask for 25 min and the first author held it for 15 min. Except for some uneasiness, none had any physical discomfort during or immediately after the mask ventilation. Next day, both had pain in bilateral hands, forearms, and shoulders. Pain was worst at the shoulders. There was difficulty in raising the arms. There was no history of trauma in either of them. None of them had any other systemic illness or other musculoskeletal problem. In both the cases, pain responded well to ibuprofen and paracetamol. We attributed this painful condition to the difficult mask ventilation because there was no other cause for this pain and the nature of pain including onset, duration, and relief was similar in both cases. Since the pain was relieved with medication, no investigation was done. For holding the mask, both the anesthesiologists kept their elbows flexed and shoulders abducted for a long period. Moreover, for the convenience of the fiberoptic intubation and the tracheostomy, the bed of the patient was kept at a quite lower position. So during mask ventilation, we had to lean forward to hold the mask. The prolonged abnormal posture for mask ventilation resulted in severe strain on the musculoskeletal soft tissues of the arms and hands. We hypothesize that the sustained strain on the musculoskeletal soft tissue of the arms and hands resulted in trauma and subsequent inflammation resulting in the development of this painful condition. There is evidence for a relationship between sustained shoulder postures with greater than 60° of flexion or abduction and shoulder musculoskeletal disorders. [1] In a large prospective study of work-related shoulder pain, working with the trunk flexed forward was found to be a strong predictor of incident shoulder pain. [2] Thus this case emphasizes that prolonged and difficult holding of face mask in abnormal postures may result in development of painful arms and shoulder of the care giver and care should be taken to avoid prolonged incorrect postures.

  References Top

1.Bernard BP. Musculoskeletal disorders and workplace factors: A critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Cincinnati: National Institute for Occupational Safety and Health; 1997.  Back to cited text no. 1
2.Miranda H, Viikari-Juntura E, Martikainen R, Takala EP, Riihimäki H. A prospective study of work related factors and physical exercise as predictors of shoulder pain. Occup Environ Med 2001;58:528-34.  Back to cited text no. 2


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