The O.P.T.I.M.A.A.L. Technique

The O.P.T.I.M.A.A.L. technique has been utilized for over 15 years by Dr. Proussaefs and his colleagues that have been trained by Dr. Proussaefs. It represents a codified sequence of actions that are indicated for patients exhibiting respiratory depression during intended minimal or moderate sedation. The acronym “O.P.T.I.M.A.A.L.” has been introduced to provide an easy to remember and follow protocol for assisting patients who exhibit respiratory depression. The sequence of actions has been taught by Dr. Proussaefs during the adult oral sedation certification courses at the California Institute of Dental Education.  


O: Observe 

Observe patient level of sedation and respiration via communication and via monitoring. Monitoring of respiration shall include a pre-tracheal stethoscope (mandated by the Dental Board of California). The operator should evaluate patient’s respiratory rate (count the number of respirations for 30 seconds and multiply by 2) , and quality of breathing (depth and quality of breaths: gargling sounds indicate presence of fluids than need to be aspirated immediately with a tonsillar suction)


P: Proussaefs maneuver

If respiratory depression is observed, then by using the elbow tilt the patient’s head and “chin” the patient with you index and thumb fingers by applying pressure in the posterior angles of the mandible. “Chinning” the patient involves moving the patient’s mandible forward. At the same time place your ear close to the patient’s nose and mouth to directly hear respirations. Observe chest movements. This maneuver allows the operator to simultaneously tilt the patient’s head, provide jaw thrust, listen to respirations, observe chest movements, and keep an eye on the monitor.


T: Tongue thrust

If respiratory depression is confirmed, the next step should be a tongue thrust. The easiest way to provide immediate tongue thrust is to utilize a 2x2 gauze to hold the anterior portion of the tongue and pull the tongue forward. Typically, in a sedated patient the tongue muscles relax and the tongue falls in the posterior wall of the pharynx. In most cases, providing tongue thrust in conjunction with head tilt and jaw thrust opens the airway and the patient resumes breathing.


I: Inspect 

While providing the tongue thrust, inspect the airway to ensure there is no foreign object or fluids that impede patient’s breathing. Ideally, this should be done by utilizing a laryngoscope; these devices have a lighting systems that assists in visualization.


M: Magill forceps

While inspecting the airway, ensure staff members have ready a Magill forceps that needs to be used in situations where a foreign object is responsible for the airway obstruction. The Magill forceps are needed to retrieve any visually detectable foreign object; they are mandated by the Dental Board of California.


A: Aspirate

After confirming that there are no foreign objects obstructing the airway, aspirate the upper portion of the airway. Utilize a tonsillar suction (mandated by the Dental Board of California). Tonsillar suction needs to be located next to the operator in any case where sedation is contemplated and be readily available in all cases.


A: Airway support

After lubricating the device, insert an oral pharyngeal airway. These devices are available at different sizes, ensure the proper size is utilized. Trained staff members should start preparing the oral pharyngeal airway as soon as respiratory depression is suspected to ensure there will be no time lapse before using them. This device effectively lifts up the tongue and opens the airway. As soon as patient resumes breathing, insert and tape the oxygen tubes from the nasal cannula within the orifice of the oral pharyngeal airway. This will ensure patient receives 100% oxygen. Alternatively, a nasal pharyngeal airway (NPA) can be inserted, however, in an emergency situation, it may take more time for a NPA to be inserted.



In a rare situation where a sedated patient is not breathing after inserting an oral pharyngeal airway, a positive airway delivery system needs to be implemented. After lubrication, insert a laryngeal mask airway (LMA) or an i-Gel. An i-Gel (a modified LMA) is preferred because it does not involve an inflated cuff. These devices effectively seal the upper respiratory portion of the airway. Assisted ventilation can be provided by attaching a bag valve mask to the LMA of i-Gel. Gently squeeze the bag of bag-valve mask to provide oxygenation to the patient. Continue to do so until patient demonstrates signs that he can start breathing on his own.


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