Med Student Airway Questions

[HLxDrummer]

Hey guys, I am a third year medical student that has been helping with airways on my ob/gyn rotation and have a few questions.

1. Any tips for mask ventilation? I feel like this is a crucial skill and I'm not very good at it. I can do it fine on mannequins but almost feel like my hands are too small on real people (doubt that is the issue, though - wear size 7.5 glove). I try to do the E-C method but either I can't keep a seal on the mask or the head falls over to the right side. Also, I know I need to lift up on the jaw but is it ok to apply pressure on the inferior surface as well? I feel like I shouldn't be closing the mouth but that's just my instinct.

2. When intubating, how do you open the mouth? I was taught to use the scissor technique but an attending today told me never to put my fingers in the mouth. He just had me push the jaw inferiorly from the side and I couldn't get it open nearly as well.

3. Any tips for avoiding teeth? I feel like I put the blade in and they are instantly so close before I apply pressure, especially without scissoring the mouth open. All I know is to pull on the axis of the handle.

4. Any tips for determining when your in the valecula? My first time I went over it with a Mac 4 (the CRNA said she liked a longer blade), the other two i undershot at first with a Mac 3. I am afraid to shove the blade down to hard/far and damage the area, but obviously can't visualize the cords without being in the valecula.

Thanks for any info you can provide. I would have asked the attendings but I didn't want to waste OR time, especially considering I'm not even on anesthesia this rotation lol. Also thanks to all of you that are patient with students. The first two attendings/CRNAs I had were super friendly and made me feel comfortable. It means a lot! The third just kept threatening to take it away if he heard me hit teeth which I understand, but just made me more nervous, especially when I was being very ginger/careful.

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[IlDestriero]

It sounds like your attendings suck. The most important skill you can learn is bag mask ventilation. You can use it anywhere and it may save a life.
These are skills you need to learn hands on and see for yourself why one thing doesn't work and a slightly different approach does. You can't teach that in a forum. As for the MAC4 blade, that's for people who are the size of Shaq. Was your patient a giant? Using a blade that big on a normal sized patient is asking for problems and unnecessary airway and dental trauma.
When I have a medical student in my OR priority one is mask ventilation, then PIV placement, then you can worry about intubating.
PS the scissor technique works well. I'd love to watch that guy intubate. He probably never actially does, just criticizes CRNAs and residents, teaching them ineffective techniques.

 

[HLxDrummer]

Well in their defense I was just waiting in the OR and asked for some instruction when they came in.

But ya, I really want to get good at the BVM... I feel like it will work well in the majority of situations, is something useful I can do as a student, and is obviously a required skill to have before you can intubate. I guess I just need to keep practicing when I get the chance (rare).

No, that CRNA used a Mac 4 on everybody I guess. Seemed a little unwieldy lol

Thanks for the info!

 

[Psai]

i can't answer your questions but you are very lucky
on my rotation they wouldn't even let me look at the epiglottis when the patient had teeth

 

[btbam]

Some people like to use the logic of using a really big blade (Mac 4, Miller 3) cause it will fit essentially everyone. When you are first learning to intubate however, it's probably not helpful to use such a large blade cause I think it throws off the fundamentals. So for an experienced practitioner I think it makes sense, but if you're brand new stick to a Mac 3 unless told otherwise.

 

[deleted171991]

2. When intubating, how do you open the mouth? I was taught to use the scissor technique but an attending today told me never to put my fingers in the mouth. He just had me push the jaw inferiorly from the side and I couldn't get it open nearly as well.

The number one cause of intubation difficulties is bad positioning. Number two is not opening the mouth enough; I see it all the time. I'd love, too, to see that genius intubating, especially during a code.

How does he place standard LMAs without getting his fingers inside the patient's mouth? Maybe he should learn how to properly induce a patient.

 

[deleted171991]

4. Any tips for determining when your in the valecula? My first time I went over it with a Mac 4 (the CRNA said she liked a longer blade), the other two i undershot at first with a Mac 3. I am afraid to shove the blade down to hard/far and damage the area, but obviously can't visualize the cords without being in the valecula.

You go in, then you come out slowly. If you see the cords, you're fine. If you see the epiglottis falling, you have just come out too much and you need to advance just a touch to push your blade into the valecula and flip the epiglottis. If you can't get the epiglottis out of the way, you could try lifting the blade. Many times that's either a positioning or mouth opening problem.

If you don't see either the cords or the epiglottis while coming out, you either need to get deeper on the next try, or you have a positioning/difficult airway/wrong blade problem.

 

[partydoc]

New CA-1, these are some things I've learned and this is what I tell the students working with me.

1. Any tips for mask ventilation?
- Practice, practice, practice. The mask is like an inner tube, too much pressure on one side will tip it over and you will end up with a leak. Try not to press the soft tissues bc it will compress everything and make it harder to move air. Also, don't be afraid to put your fingers close to the prongs the strap attaches to, it will give you more control over the right side of the mask.

2. When intubating, how do you open the mouth?
- I never scissor the mouth. I usually give the head some slight extension, the mouth usually just falls open.

3. Any tips for avoiding teeth? I feel like I put the blade in and they are instantly so close before I apply pressure, especially without scissoring the mouth open. All I know is to pull on the axis of the handle.
- Do not turn the blade on it's axis. Pretend like you are lifting a milk jug to the corner of the room.

4. Any tips for determining when your in the valecula?
- Practice this on a mannequin. Put the blade down as far as you can go, and pull back a little bit and take a look. Pull it back again a bit and take another look. Do this a few times, you will get the feel of how far in or out you need to move the blade to get a decent view.

 

[Noyac]

The number one cause of intubation difficulties is bad positioning. Number two is not opening the mouth enough; I see it all the time. I'd love, too, to see that genius intubating, especially during a code.

How does he place standard LMAs without getting his fingers inside the patient's mouth? Maybe he should learn how to properly induce a patient.

I never put my fingers in a pts mouth. Never. Ok maybe once in a while when placing an OG TUBE.

 

[deleted171991]

I never put my fingers in a pts mouth. Never. Ok maybe once in a while when placing an OG TUBE.

And you never have to lift your blade either, right?

I am not pulling your leg. I find that if I do good scissoring and subluxate the jaw, I barely have to lift the blade. Hence much less soft tissue damage. Same with putting my fingers in the mouth to guide the LMA.

 

[jwk]

I never, ever, put my fingers in the patient's mouth during intubation. I got berated for it by an old anesthesiologist when I first started in practice and learned to do it the right way. Nobody, myself included, wore gloves back then, but one reason was we didn't stick our hands where they didn't belong. Take time inserting the blade (Mac of course), get it in position, then lift.

 

[PianoMedic]

I'm a first year, but have about 25 intubations between the OR and field as a paramedic student and working. EC clamp for the mask is what I was taught and had drilled into my head. Mannequins have a lot more resistance back at you so it is easy to be pushing the mask into their face like you described. I've had several anesthesiologists tell me to put my pinky on the angle of the mandible, middle finger under the chin and ring finger halfway between. The seal for me comes from having the tips of my C fingers on the opposite side of the face and pushing down with them while I pull and head tilt with my E fingers. This does somewhat close the mouth for me, but I get adequate chest rise.

I was also taught to scissor the jaw, but I was getting worried that I might be dislocating the jaw instead of subluxating it, so my most recent intubations were done by opening the mouth using my right hand on the chin. Mac 3 as others have stated for sure. Easiest way to learn (my preceptors put a miller in my hand for the first dozen attempts).

I had one preceptor show me a very odd way to use the mac, but not sure if it is a good way. I'd like some attending opinions on it. He opened the jaw enough to insert the blade and wouldn't watch it from the side as it went along the tongue. He would remain looking down watching lips and teeth while inserting until he met resistance, keeping the blade in contact with the tongue. Then he would perform his visualization and would have cords nearly every time. I never had the guts to try that as I like to see where that hard metal blade is going. Has anyone else seen a mac used like that?

 

[Noyac]

And you never have to lift your blade either, right?

I am not pulling your leg. I find that if I do good scissoring and subluxate the jaw, I barely have to lift the blade. Hence much less soft tissue damage. Same with putting my fingers in the mouth to guide the LMA.

I know your not trying to antagonize me. I just have a different way of doing it than you do. I grab the top of the head with my right hand and slightly tilt it backwards. This maneuver will open the mouth enough to gently slide the blade into the posterior oral pharynx while resting my little finger on the chin in order to pull the lower lip away from the blade so as not to pinch it btw the blade and lower incisors. I then see the epiglottis and position the blade appropriately. Very little pressure needed. Works well for me.
I do something very similar for LMAs. I grab the top of the head and gently tilt backwards. As the mouth opens I slide the LMA in with a slight sideways approach to allow the tongue to not be pulled back in the throat. Once past the base of the tongue I twist it back upright and advance until seated. Works every time.

 

[Noyac]

Pianomedic, I would say your preceptor probably had intubated so many pts that he/she probably knew just about how far they needed to advance before actually having to visualize.

One thing I do is to not start looking for cords until I have advanced the blade to the depth I think is "nearly" perfect. Then a slight lift and whala there they are. I rarely even attempt to optimize my view to the point of a grade 1 since that takes more pressure or lifting as FFP elluded to. If I see the arytenoids and the beginning of the cords or tracheal opening then I just slip in. If the tube hangs up any then I improve the view but that is rarely necessary.

 

[IlDestriero]

Some of the new residents and most of the CRNAs have been placing LMAs with tongue depressors. What's that nonsense? I do what Noy does. Works every time.
I tell them its not necessary, even demo it, stealing their airway, but they still do it. Many don't lube it either, which is probably why they have problems placing them.
Who teaches this stuff?

 

[deleted171991]

The same people who teach that an LMA needs to be deflated before removal.

 

[Noyac]

Or deflated in order to place it.

Something for newer people to think about. If you place or remove an LMA and there's blood on it, your doing it wrong. This should be an atraumatic airway device. If not then why use it?

 

[deleted547339]

Any of you guys using the i-gel? Thoughts?

 

[deleted171991]

Any of you guys using the i-gel? Thoughts?

My favorite LMA, especially for (morbidly) obese people.

 

[deleted547339]

My favorite LMA, especially for (morbidly) obese people.

Thanks. We recently added them to our ED airway cart. I've played with them on mannequins, but only once on a patient. Went in easily, got good ventilation. Just only have an n of 1 and was curious what the folks upstairs thought.

 

[deleted171991]

Just make sure you stock at least from size 2.5 up. I have seen many women whose airways are too small for size 3.

 

[risnwb]

I know your not trying to antagonize me. I just have a different way of doing it than you do. I grab the top of the head with my right hand and slightly tilt it backwards. This maneuver will open the mouth enough to gently slide the blade into the posterior oral pharynx while resting my little finger on the chin in order to pull the lower lip away from the blade so as not to pinch it btw the blade and lower incisors. I then see the epiglottis and position the blade appropriately. Very little pressure needed. Works well for me.
I do something very similar for LMAs. I grab the top of the head and gently tilt backwards. As the mouth opens I slide the LMA in with a slight sideways approach to allow the tongue to not be pulled back in the throat. Once past the base of the tongue I twist it back upright and advance until seated. Works every time.

I do exactly the same thing. I think I started doing it because I was wasting time changing gloves to avoid getting saliva all over everything. Works great, looks slick, and no spit on my gloves.