10 Awards Reviews     

What is this?      Just a plastic bag?!

"It is a Tse mask!" Charles Brandwein, MD, 2001

"It is Totally Simple and Easy!"
Jacqueline Gladdis, R.N., 2006

"So Easy! Anesthesiologists can do it!!"
James Tse, PhD, MD

"Why don't you call it 'TSE-Alloteh CPAP'?"
John Denny, MD, 2013

"Nasal Tse-PAP Mask Assembly" Jack (John A.) Pacey, MD,
FRCSc, GlideScope Inventor, 2015
Gliscopejack: Near Perfection in Airway Management is Now
Possible..Modified Pediatric Nasal Mask, Feb 19, 2018


The demand for off-site anesthesia care has been
increasing in the recent years at the Robert Wood
Johnson University Hospital in New Brunswick, NJ.

The off-sites include Endoscopy/Bronchoscopy Suite,
Cardiac Echo Lab, Cardiac Cath Lab, Radiology/Special
Procedure Suite, CT- Scan/MRI Suite, Infertility Clinic,
ER and ICUs.

These off-sites pose many challenges for
anesthesia care providers, such as less-than-ideal
anesthesia set-ups, small crowded and dark
rooms, help from another anesthesiologist is far
away, production pressure for rapid turnover,
high expectation, high-risk patients
, etc.

It is especially challenging during EGD, EUS,
ERCP, PEG, bronchoscopy and TEE.  

An O2 reservoir is lost when the patient’s mouth
is kept open with a bite block (Photo 1).
A nasal
becomes ineffective and delivers only
minimal O2
(<0.30 FiO2).

Furthermore, the airway is often compromised by the

Oxygen desaturation is a common occurrence in
patients receiving moderate-to-deep sedation
during upper GI endoscopic procedures.

According to ASGE Guideline (2012), large series
report adverse event rates of 1 in 200 to 1 in
10,000 and mortality rates ranging from none to
1 in 2000. Data collected from the Clinical
Outcomes Research Initiative database show a
cardiopulmonary event rate of 1 in 170 and a
mortality rate of  1 in 10,000 from among  
140,000 UGI endoscopic procedures. For more
information, please go to
ASGE Guideline:
Adverse Events of Upper GI Endoscopy, BSG
Guidelines in Gastroenterology: Complications of
GI Endoscopy and SGNA Risks & Complications

We have used a simple plastic sheet to convert an
ineffective nasal cannula to a face tent since 2001
(Photo 2-5

It takes 10 seconds to prepare at bedside and provides
FiO2 of 0.50-0.70 with the nasal cannula O2 flow rate
of 4-5 L/min.

It improves patient’s oxygenation, prevents
severe desaturation, decreases the need for
assisted ventilation and reduces the
interruptions of the procedures.

How to Make a Tse "Mask"

We make a 12" x 12" or larger plastic sheet utilizing any
clean, clear plastic bag (nasal cannula bags, specimen
bags, face mask bags, breathing circuit bags, etc.) or the
clear plastic shield of a fluid-shield surgical mask .

After the patient assumes the lateral decubitus, prone
or supine position, we put a nasal cannula on the
patient and then place a clear plastic sheet over the
patient’s head covering the eyes, the nose and the
mouth, and secure it with tape.
(Photo 2-7)

In less than 10 seconds, a nasal cannula is converted
into a face tent that provides FiO2 of 0.50-0.70 with O2
flows of 4-5 L/min.

Upper GI Endoscopy, FOB or TEE
During manipulation of the endoscope, we lift the
plastic sheet slightly to avoid dragging it into the

The zip-lock specimen and face mask bags are easy to
use because the rigid edges can stand up like a tent with
an open door
(Photo 2-4)

The soft plastic sheet can also be re-enforced with one-
inch silk tape.
(Photo 5)
When we use a plastic shield from a fluid-shield
surgical mask, we tape the plastic sharp edges to
avoid corneal abrasion. (Photo 6)

After explaining to the patient that by applying this
plastic sheet we will be increasing O2 supply and ask
the patient to close  the eyes, even the most anxious
patients are receptive.

Following pre-oxygenation using this technique for 1-2
minutes, we titrate propofol or other sedatives to
achieve moderate-to-deep sedation while maintaining
spontaneous respirations.

Keep a Patent Airway and Monitor

We position patient’s head and neck to maintain a
patent airway.
For patients with upper airway obstruction, serial
dilation with well-lubricated nasopharyngeal airways
may avoid causing nasal bleeding.
We monitor the patient’s respirations using
capnography, with or without a pediatric precordial
stethoscope placed over the trachea.
This face tent also improves CO2 sampling and makes
early detection of respiratory depression possible.
If the patient becomes apneic because of airway
obstruction or over-sedation, we have an average of
to manipulate the airway and/or to decrease
the level of sedation before desaturation occurs.

Rebreathing of CO2?

One concern is that a plastic sheet could increase "dead
space" resulting in re-breathing of CO2 and hypercarbia.
We routinely monitor CO2 using capnography. By
maintaining the plastic sheet in
a tent-like position with an open door, we can avoid re-
breathing of CO2
(Photo 7).

Monitored Anesthesia Care   

The line between deep sedation and total intravenous
anesthesia is very fine.
Deep sedation often turns into general anesthesia.
Anesthesia providers should always be ready to manage
patients under general anesthesia.

If a nasal cannula is used for deep sedation, a TSE "Mask"
will improve patient’s oxygenation.
We have used this face tent for short procedures
(D & C, hysteroscopy, LEEP,cystoscopy).

If opioid analgesic is needed, titrating in small
increments of analgesic would maintain spontaneous

Patient selection is important to decrease the risk of
pulmonary aspiration.

Premedication of the patient with metoclopramide may
decrease the risk of gastric reflux.

Nasal Tse-PAP Mask/Circuit
Assembly to deliver CPAP,
BiPAP, CF (continuous flow) or
Assisted Nasal Ventilation for
Patients with or without  OSA
under MAC (EGD,
colonoscopy, bronchoscopy,
TEE, etc.), Awake Intubation
or G

(Provisional Patent filed on Oct 30, 2013 and
Formal Patent Application filed on Oct 29, 2014
by Rutgers University for a similar assembly.
James Tse and co-inventors have transferred the
invention to RU for one dollar.)

(Please see updated Practice Guidelines for
Perioperative Management of Patients with
Obstructive Sleep Apnea.
Anesth 120: 268-86, 2014
or Google search "2014 ASA Guidelines OSA" for a pdf

Patients under monitored anesthesia care
(MAC) receive intravenous sedation and O2
via nasal cannula (NC). Over-sedation
and/or airway obstruction may cause
severe desaturation, especially in obese
patients with OSA.

Even with a face tent (TSE "Mask"), obese
OSA patients may require frequent chin-
lift, jaw-thrust and/or insertion of nasal

Inserting nasal airways may cause bleeding
despite using small, well lubricated nasal

On January 24, 2013, a nasal TSE-PAP
mask/circuit was developed using an infant
face mask (Photo 11-13). It  was successfully
used in 3 sedated patients with  and without
OSA the next day to improve spontaneous
ventilation and oxygenation during EGD.

The effectiveness of nasal ventilation in
anesthetized patients and unconscious
apneic adults has been shown by Liang et.
al. (Anesthesiology 108: 998-1003, 2008
Anesthesiology 108: 998-1003, 2008) and
Jiang et. al. (Anesthesiology 115: 129-35,
 Anesthesiology 115: 129-, 2011)

The nasal TSE-PAP mask is especially useful
for EGD and TEE under MAC. With the bite
block in place, CPAP is about 1-2 cm of H2O
even with the APL valve completely closed.  

However, it becomes CF mask with fresh O2
flow of 4-5 L/min. Fresh air can be added to
keep FiO2 under 0.8 to avoid causing
absorption atelectasis (Photo 11-18).

Adjust the APL valve to deliver 4-8 cm
H2O CPAP as needed and avoid over-
inflating the reservoir bag.

If the patient becomes
apneic or the airway is obstructed by
the endoscope, assisted ventilation
can be immediately delivered without
interrupting the procedure. It should
be done with small volume to keep PIP
under 20 cm of H2O to avoid gastric


Should you have any question for
the safe use of this technique,
please contact us via
or email (james.tse@rutgers.edu)

It improves oxygenation
and can be used to pro-
actively  prevent
desaturation in obese
patients with OSA.
( Please see Publications #70 & 71,
81-85, 87-95)
(Patients consented for

This nasal mask assembly
has also been used for
awake FOB and/or video
laryngoscopy assisted
endotracheal intubation
(Photo 19a-c) and
preoxygenation and assisted
nasal ventilation for
patients with poor face-
mask fit during induction of
general anesthesia
(Please see Publication and Presentation).

A Modified TSE "Mask"
for Upper Body

Fire Hazard Precautions

Do not use a plastic bag or
a plastic sheet
for upper
body procedures, such as
breast biopsy or thyroidectomy
avoid high O2
concentration Pooling
under the surgical drapes.

Taping a fluid-shield surgical
mask firmly to the lower jaws will

the risk of  FIRE
(Photo 22-24)
It increases O2 supply to the
patient and avoids O2 pooling
under the surgical drapes close to
the surgical site.

Our preliminary data show that
O2 concentration under the
surgical drapes is close to 22% by
using this modified TSE "Mask".

It also keeps the surgical towels or
drapes from
covering the patient's face.

It is very important to
protect the eyes. Tape the
sharp edges of the plastic
shield to avoid corneal
(Photo  22-24)

Even though there are
commercially available devices for
endoscopies or for patients with
mouth breathing (Photo 20-24),
this technique utilizes plastic
sheets which are ubiquitous and
available at no additional cost.

We also use this technique for patients
undergoing rectal procedures in the
jack-knife position (Photo 25), pain
management procedures in the prone
position, retrobulbar block (Photo 28)
and pediatric procedures (endoscopy,
PICC, spinal tap, bone marrow biopsy,
MRI, CT Scan, etc.).

Prone Position: Use pillows to
support the upper body and head
to maintain a patent airway.
For patients with upper airway
obstruction, serial dilation with
well-lubricated nasopharyngeal
airways and chin lift may open the
airway. Use a large clear plastic
sheet to create a large O2 hood
(Photo 8 & 25).

If patient's oxygenation fails to
improve, attaching an anesthesia
breathing circuit to a
nasopharyngeal airway using an
ETT connector delivers high
concentration of O2 directly into
the oropharynx (Photo 26-27):

1. The connector from a 7.0 ETT
fits well with 30-34 Fr
nasopharyngeal airways (so does a
6.0 or 8.0 ETT connector with 26-
30 Fr and 32-34 Fr
nasopharyngeal airways,
respectively) (Photo 27).

2. O2 flow is usually set at 4-6
L/min and the circuit pressure
relief valve is opened.  

3. To avoid trauma to
nasopharyngeal tissue, a well-
lubricated small nasopharyngeal
way (26 or 28 Fr) is gently inserted
to make sure there is no resistance
in the airway. After replacing it
with an appropriate
nasopharyngeal airway, the ETT
connector is connected to the
nasopharyngeal airway and the
breathing circuit is then
connected to the ETT connector.

4. If the reservoir bag is over-
distended, we need to adjust the
pop-off valve to ensure that O2
flow is not excessive which may
force secretion into the trachea
and/or cause tissue injury.

5. The patient may breathe
through the breathing circuit if
the nasopharyngeal airway is the
only patent airway. By adjusting
the pressure relief valve, it
provides CPAP that may prevent
airway from collapsing.  

6. If the patient is apneic because
of over-sedation, this technique
allows low positive pressure
ventilation in order to gain time
for sedation to wear off or for
turning the patient supine to
perform assisted ventilation.  

7. We are always prepared to
ventilate and oxygenate the
patient using a bag-mask or ETT if
this approach fails to improve
oxygenation quickly.

Retrobulbar Block (Photo 28-
: Tape the face tent over the
bridge of the nose and lower
cheeks for
pre-oxygenation, and
remove it
before sterilization preparation to
avoid suffocating the
patient (Photo 29)!!

exible Fibro-optic
Bronchoscopy (FOB)

Tape the specimen plastic sheet
on the forehead and both
cheeks. Cut a hole near the
nose or the mouth or tear the
plastic sheet to middle to allow
bronchoscope for oral (Photo
30) or nasal (Photo 31)
insertion of  bronchoscope.
Overlap and tape plastic sheets
together  to avoid O2 from

Modified TSE "Mask" to
of Combative Trauma
Patients for Emergency
Endotracheal Intubation
(Photo 32)

Since 2006, many
anesthesia attendings in the
Department of
Anesthesiology have
contributed their time and
their own financial
resources to teach the use
of these simple techniques
national and
anesthesiology meetings.
Our main goals are to
improve patient safety and
reduce healthcare costs.

Special thanks to all the
anesthesia attendings (Dept.
Anesthesiology & Perioperative
Medicine, Rutgers RWJMS(formerly
UMDNJ RWJM0S who have
supported us with extra
time to present our clinical
findings as poster
presentations and
demonstrate this technique
as Scientific and
Educational Exhibits.  
Publications/Poster Presentations     

Please see Anesthesia Patient
Safety Foundation 5 Reviews
(2007-2010, 2013, 2014) and
Anesthesiology News Review
(2009 & 2016)
Welcome to www.TseMask.com     

The Simple Combined Nasal Tse-PAP Mask-Face Tent for
Reducing Aerosol/Droplet Spread and Providing
Continuous Nasal Oxygenation & Additional Provider
Protection during MAC, GA induction, Endotracheal
Intubation and Extubation
The Original Tse "Mask" (Face Tent) & Nasal Tse-PAP
Mask/Circuit  Assembly for Improving Oxygenation &
Patient Safety
Photo 1. Upper GI Endoscopy,
. With the mouth
kept open by a bite-block, a
patient receives only minimal
O2 via a nasal cannula.
Airway obstruction,
respiratory depression or
over-sedation easily leads to
severe O2 desaturation.     
Photo 2. Secure  the plastic
sheet  with
taping along the
forehead and the cheek.
Tape the clear plastic sheet
above the eye and make
sure eyes are closed and
Photo 3.  Tape along the
lower jaw.
Photo 5. Double taping  the
edge of a soft plastic sheet
to  strengthen
the face tent
to avoid interfering with the
Photo 4. The rigid edges of  
zip-lock bag stand up like
tent with an open door.
Photo 7. ERCP in lateral
decubitus position
pulse oximetry, O2 and
Photo 8. ERCP in prone
Photo 9. TEE, PEG or FOB in
supine position.
Photo  20.  With mouth
breathing, a nasal cannula
delivers minimal O2  a
produces a
poor ETCO2
Photo 21.   Lower Body
Procedures, Cardioversion
or AICD testing
: Tape the
plastic sheet  to the bridge of
the nose and cheeks or tape it  
to the forehead to cover eyes,
the nose and the mouth.
.  Keep
the lower portion open to
avoid re-breathing CO2. Do
not use a soft plastic sheet
to avoid it from collapsing
and being sucked into the
Photo 22. Upper body
: Tape a
fluid-shield surgical mask
firmly  to the lower jaw.
the sharp edges
of the
plastic shield to  
Photo 23. This modified TSE
"Mask" for
upper body
procedures increases FiO2 ,
prevents O2 pooling under
the surgical drape
reduces the risk of FIRE
Photo 28.   
Pre-oxygenation for
retrobulbar block.
Photo 25. Jack-knife or Prone
. Use pillows to support
the upper body and head to
maintain a patent airway. Tape a
large clear plastic sheet like a drape
over the head. Keep the bottom
open to avoid rebreathing CO2.
Photo 6. A plastic shield from  
a fluid-shield surgical mask.
Photo 10.  A plastic shield from  
a fluid-shield surgical mask.
Photo 26.       A simple and
rescue technique: An
anesthesia breathing circuit
connected to a
nasopharyngeal airway using
an ETT connetor in a
deeply-sedated patient with
upper airway obstruction in
jackknife position.
Photo 27.  An anesthesia
breathing circuit is
connected to a
30 Fr.
Nasopharyngeal airway
using a
7.0 ETT connector.
Photo 24.  This modified TSE
" Mask" keeps the surgical
drapes from covering the
face and O2 from pooling
under the surgical drapes.
Photo 31. FOB nasal
Photo 30. FOB oral
Photo 29. Remove it before eye
sterilization preparation to
Photo 32. Secure nasal
cannula with tape, turn O2
flow to 10 L/min and put the
head in a large, clean, clear
plastic bag. Pre-oxygenate
for a few min, RSI of general
anesthesia and remove the
bag before intubation.
Photo 11. How to
assemble a
nasal Tse-PAP
Inflate the air cushion of
an infant face mask with
about 10 cc  of air and
secure a hook ring from a
toddler mask or an adult
face mask with tape.
Photo 12. Secure the mask
with head straps to obtain a  
good seal and to avoid
compressing the eyes.
Connect it to the adult
anesthesia breathing circuit.
Tape the nasal cannula to
the lower rim of the bite
block for capnography.  
Photo 13. Pad under the
straps to avoid excessive
compression pressure on
the facial nerves. Cover the
mouth with a clear, clean
plastic sheet (Tse "Mask")
to improve the quality of
capnography and reduce
aerosol spread.
Photo 14. A patient with OSA
under deep propofol sedation
during EGD.
A nasal TSE-PAP mask is
connected to an adult breathing
circuit and an anesthesia
machine. The pop-off valve is
closed. Fresh O2 flow is set at 6-8
L/min. Fresh air can be added to
keep FiO2 under 0.8.
Photo 15. The patient is
breathing spontaneously as
indicated by the capnography
obtained with an air sampling
line of  a nasal cannula.
Photo 19.       TEE at the
Echocardiology Lab (no
anesthesia machine). A Nasal
TSE-PAP mask connected to a
mask-bag (+ PEEP valve) with
a flexible extension and a wall
O2 outlet (8-10 L/min O2 flow).
Photo 16. EGD with
Photo 17.   Nasal TSE-PAP
Mask/Circuit for an OSA
Patient under MAC during
Photo 18. Nasal TSE-PAP
mask/Circuit for an
OSA patient under MAC
during Hysteroscopy and

Videos:  How to use Nasal TSE-PAP Mask/Circuit
to improve oxygenation in an OSA patient under
propofol sedation during SVT Ablation  in Cath Lab
How to use Nasal TSE-PAP Mask/Circuit to
improve oxygenation in an OSA patient under
remifentanil infusion during Atrial Flutter
Ablation  in Cath Lab
Video: How to Improve Oxygenation using a Tse "Mask" during EGD.
10 Awards including the
2008, 2013, 2015 & 2016
PGA "Best Exhibit for
Clinical Application"
Photo 19a. Video
Laryngoscopy assisted
endotracheal intubation
Photo 19b. FOB assisted
endotracheal intubation
Photo 19c. Combined video
Laryngoscopy and FOB
assisted endotracheal
Photo 19d. Pre-oxygenation
and assisted nasal
ventilation during induction
of general anesthesia in a
patient with full beard.
Photo 19e. Pre-oxygenation and
assisted nasal ventilation
during induction of general
anesthesia in an edentulous
patient .
Photo 19f-g. Pre-oxygenation
and assisted nasal
ventilation during induction
of general anesthesia in
obese patients with poor
face-mask fit.
2014 3rd Place Award for Scientific/Educational Exhibit at the ASA Annual
Meeting, New Orleans, LA, Oct 2014, (Feb 2015 ASA Newsletter, page 40-41)
& Anesthesia Patient Safety Foundation E.C. Pierce, Jr., MD, Award for "Best
Scientific Exhibit" (APSF Newsletter February 2015, page 48).
A Technically Simple and Effective Universal Precaution
             in addition to the Recommended PPEs
amid the COVID-19 Pandemic, March 2020 & Beyond

Combining the Nasal Tse-PAP Mask-Face Tent & Suctioning under  the Face Tent May
Reduce Aerosol/Droplet Spread and Provide Continuous Nasal Oxygenation & Additional
Protection to Providers during MAC, GA Induction, Video-Laryngoscopic Endotracheal
Intubation and Extubation
see Publications #334-340 for 2020 ASA/PGA & 2021 SOCCA/IARS ePosters
Fig. 1. A tear-drop shaped pediatric facemask is
modified to a rounded triangular nasal mask by
squeezing it for 1-2 mins.
Fig. 2. An infant mask (left) and the modified infant
mask (right) that fits most adult noses. The air cushion
is injected with 10 cc air.
Fig. 3. A large clean specimen bag is taped to the lower
part of the mask and an adult hook-ring is then taped
over the plastic sheet and the mask.
Fig. 4. A nasal mask-face tent connected with a circuit
and a filter is placed over the nose first and then
secured with elastic head-straps to obtain good
nose-mask seal.  
The head-straps are crossed over each
other to avoid causing eye injury.
Fresh O2 flow of 4 L/min
should be adequate for pre-oxygenation in the OR.
Fig. 5. A patient received pre-oxygenation
with a nasal mask-face tent.
Fig. 7. If the mouth is open, hold the nasal mask
with the thumb and the index finger and close the
mouth with other fingers over the plastic sheet.
Fig. 9. A disposable video-laryngoscope
(free-standing or hand-held) can be inserted
under the plastic sheet without lifting the cover.
Fig. 10. Adjust the VL and keep the plastic sheet
cover the mouth.
Uses of the Original Tse "Mask" (FaceTent) (since 2001)  
and the Nasal Tse-PAP Mask/Circuit (since January 2013)
Fig. 11. Keep the plastic cover in place.
Fig. 12. Insert the endotracheal tube under the
plastic sheet.
Fig. 14. Inflate the ETT cuff first and disconnect
the breathing circuit and connect it to ETT.
Fig. 15. After intubation, check to make sure the
ETT is in the correct place.
Fig. 16. Following intubation, oral suctioning
can be done under the mouth cover. Then,
dispose the used plastic sheet properly.
Fig 18. OGT suctioning prior to extubation.
Fig 21. For extubating a patient with nasal tube,
a clean plastic sheet can be used to cover the
nose or the forehead.  Following extubation, the
nasal mask with the plastic sheet can be secured
again as described above.
Fig 19.Prior to extubation, the combined nasal
mask and another clean plastic sheet can be
secured over the nose and be ready to use.
Immediately following extubation, check
ventilation through the nasal mask with the
mouth closed as in Fig. 6 and suction the mouth
under the plastic sheet.
Fig 20. Immediately following extubation, check
ventilation through the nasal mask with the mouth
closed as in Fig. 6 and suction the mouth under the
plastic sheet.
Disclaimer: This website is intended for suggestions only and should not be construed as providing
medical advices. The content is not a substitute for the individual practitioner's medical judgment, and
the use of the suggestions portrayed in this website is solely the decision of the individual practitioner.
Dr. James Tse, his colleagues and Rutgers University assume no liabilities for the uses of these
Fig. 17. A clean plastic sheet is taped to the
forehead to cover the nose and the mouth during
Fig. 13. Inserting a hand-held VL under the face
Fig. 22. Transport a  patient to PACU with a face tent
(nasal cannula O2 + a clean plastic sheet covering the
nose and mouth). It traps aerosol/droplet and
increases FiO2 during transport.
Fig. 6. A BVM device (Ambu bag) with a flexible
connector and a filter can also be used with wall
O2 supply at the NORA locations. With the PEEP
closed, a low O2 flow (5 L/min) could be used. (A
plastic cover and a filter not shown).
Fig. 8. RSI following pre-oxygenation.