In a thought-provoking study, assessing the effects of muscle relaxants on facemask ventilation (FMV) in the anesthetized patients with normal upper airway anatomy, Ikeda et al. 1 showed that rocuronium did not deteriorate FMV without airway interventions, and FMV was improved after succinylcholine administration in association with airway dilation during pharyngeal fasciculation. However, apart from the limitations described in the discussion, there are two aspects of this study that should be

more »

... discussed. First, it would be interesting to know why this study was performed in a neutral head and mandible position without airway interventions, which are not the practical airway management methods during anesthesia induction. Actually, upper airway obstruction is common during anesthesia induction due to loss of muscle tone present in the awake state. 2 To obtain an adequate FMV and then make an easy laryngoscopy, a sniffing position is generally recommended in the clinical practice, especially for the patients with a difficult airway. 2,3 A previous study from the authors' team in patients with obstructive sleep apnea showed that compared with the neutral position, the sniffing position structurally improved maintenance of the passive pharyngeal airway at both retropalatal and retroglossal segments, 4 which are the most common sites of upper airway obstruction. 5 Moreover, the simple airway interventions, such as head tilt, jaw thrust, and open mouth (known as the triple airway maneuver), are the reliable methods frequently used to achieve upper airway patency in the anesthetized patients. 2 The another study from the authors' team showed that anesthesia induction and complete paralysis caused the upper airway obstruction in all patients with obstructive sleep apnea when the jaw thrust was not performed, while a combination of head tilt and jaw thrust restored airway patency and allowed adequate FMV ventilation. 6 Considering the fact that the four patients in the rocuronium group were excluded from this study because of inadequate FMV, we would like to know whether the study design required a minor or moderate upper airway obstruction by a neutral head and mandible position without airway interventions. It is certain that the head and neck position of the anesthetized patients can affect the longitudinal tension on the upper airway and the manual airway interventions may change the caliber of the retrolingual and retropalatal airways, worsening or improving airway patency. 2,5 Thus, we believed that if the patients are placed in a sniffing position with airway interventions in this study, as needed in the routine anesthesia induction, different result would have been obtained. In Reply: We thank Dr. Dexter for his comments about our recent article. 1 We agree with him about the need for effective leadership practices to be rooted in both evidenced-based behavioral and management science. The efficiency measures presented in our case were selected for illustration purposes but do reflect an aggregate of practices that we understand have been implemented at various institutions, even if some of them may be misguided as highlighted by Dr. Dexter. The reaction of the residents to such efficiency measures is based on discussions by Dr. Scemama with residents at his and other institutions. Dr. Dexter seems to draw a distinction between behavioral and leadership principles. As discussed in our case scenario, the foundation of leadership is behavioral, 1 and effective leadership requires the ability to recognize and to navigate both our own and others' cognitive, emotional, and relational biases. The successful implementation of process improvement requires both sound management science and effective leadership. We believe that the intersection between effective leadership and management science in anesthesiology is an exciting area for further investigation.