We learned to intubate today!

[fiznat]

As some of you already know, I'm currently in medic school. This weekend marked a month and a half that we've been working, and I have to say I am still PUMPED to be doing this stuff! Everyone told me beforehand that medic school would eventually run me into the ground and sap me of that excitement and (I'll admit) newbie sparkeyness. But I gotta say, this far in, things have been absolutely awesome.

As the title suggests, we had lab today to start learning intubation techniques. We got to play with all the toys, get a few tubes on the dummies and stuff. I wanted to ask you already experienced paramedics- what kinda blades do you like to use? I got to try a few times with both the Miller and Macintosh types, and I gotta say that I am much more a fan of lifting the epiglottis directly with a Miller instead of indirectly by using the vellicula. I found myself doing this even with the Mac type blades: just getting a longer blade and still lifting directly. The instructor said that it is much easier to do it this way on the dummies because they tend to offer much more resistance to indirect lifting, whereas real patients things tend to be much more supple.

Just wanted to see what you guys prefer as far as blade types and technique, and also if you have any advice as far as tubing-- or medic school/skills in general I'd love to hear it!

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[southerndoc]

I'm more of a fan of the Mac blades. The Miller limits your view of the vocal cords.

The Mac is hard to use on a mannequin, but is easier (in my opinion) on a real person. I reserve the Miller for difficult airways.

 

[12R34Y]

I am absolutely a fan of the MAC blade. Almost exlusively. Mac 3 for most folks, but if big/tall then MAC 4 is my first choice.

I also reserve Millers for difficult airways that I can't get after a couple of tries with a MAC. In anesthesia you will find that they almost always use MAC's. Many say that it causes less trauma to the airway ie epiglottis.

Come to think of it I've probably only used a miller a few times in my career.

Of course you generally need a Miller for peds however.

good luck,

later

 

[southerndoc]

I am absolutely a fan of the MAC blade. Almost exlusively. Mac 3 for most folks, but if big/tall then MAC 4 is my first choice.

I also reserve Millers for difficult airways that I can't get after a couple of tries with a MAC. In anesthesia you will find that they almost always use MAC's. Many say that it causes less trauma to the airway ie epiglottis.

Come to think of it I've probably only used a miller a few times in my career.

Of course you generally need a Miller for peds however.

good luck,

later

Macs do cause less trauma than Miller blades. There have been several cases reported of esophageal perforation from Miller blades. Just think about it. The correct technique is to blindly insert the Miller all the way in, lift up, and pull back until you see the vocal cords (or the epiglottis fall down, at which point you readvance and lift up the epiglottis directly). Pulling up on the blade while it's in the esophagus is setting up for an esophageal perforation.

 

[12R34Y]

Macs do cause less trauma than Miller blades. There have been several cases reported of esophageal perforation from Miller blades. Just think about it. The correct technique is to blindly insert the Miller all the way in, lift up, and pull back until you see the vocal cords (or the epiglottis fall down, at which point you readvance and lift up the epiglottis directly). Pulling up on the blade while it's in the esophagus is setting up for an esophageal perforation.

Agreed.

Also much easier to damage the cords if you go sticking this long steel blade into the larynx and then "back up". think about where it was before you backed up. Right in between the vocal cords. OUCH

 

[fiznat]

So when using the Mac, do any of you guys use it to lift up the epiglottis directly like you would with a Miller? The opportunity is certainly there to use the Mac both ways, especially if you go with a slightly larger blade. I was using a Mac 4 to do this on the dummy: into the vellicula as usual till i saw the epiglottis dangling there, then I reached back just a little bit more to grab it that way.

Also, I noticed that the Mac blades tend to have a much bigger "foot" on them towards the handle, which makes it harder to avoid the teeth. I'd imagine its even tougher in small-mouthed people. Comments?

 

[ShyRem]

As a medic of over 10 years, I also vote for the mac. Much easier for real-person intubation. However, I usually use a miller for small children (due to the inherent floppy epiglottis) and morbidly obese people (where you use two people for the tube - one to lift the blade, one to slip the tube).

Never had a problem with the 'foot' of the mac blade, even in smaller people (and I've seen some pretty small people). Either way, you use very specific arm muscles for the peculiar angle you must lift the blade. The teeth should never be a problem as you shouldn't be prying anyway - just lifting.

Oh, and to answer your question, I use the mac as intended with the tip in the vallecula (sp?). I have tried using it as a miller, but just catching the tip you can get some bulging at the base of the epiglottis. Using the tip in the vallecula lifts the epiglottis more completely out of the way imho.

 

[12R34Y]

I have never used the MAC as a miller by directly lifting the epiglottis.

This is all kind of a moot point until you can get into the OR and do some real tubes on real patients. I think you'll find that the view you obtain from lifting in the vallecula is awesome in my opinion.

Again, I've never had any trouble with teeth using a MAC4 in 8 years as a medic. YOu NEVER pry.... you lift and should never really contact the front teeth at any point.

I think once you get into the OR (which they'll probably give you a MAC) you'll see it is the preferred blad (iMHO).

later

 

[rn29306]

Agreed with the MACs. Have used the Miller only a couple of times in the OR on adults. The Miller will tend to limit your view of the VC vs the full, unobstructed view of the MACs.

See what happens in the OR. Most practitioners will use a MAC.

 

[Apollyon]

The correct technique is to blindly insert the Miller all the way in, lift up, and pull back until you see the vocal cords (or the epiglottis fall down, at which point you readvance and lift up the epiglottis directly). Pulling up on the blade while it's in the esophagus is setting up for an esophageal perforation.

We've never discussed where you did paramedic school, but this is ABSOLUTELY the opposite of what I was taught (at 2 different schools, one for EMT-I, and one for EMT-P). Absolutely the opposite of what you assert as law (which I cannot find 100% justification for - in fact, I only find 1 source on a straw poll of Google that advocates what you say, whereas the others support how I was taught), the manner in which I was instructed was a "progressive laryngoscopy" - to deliberately (but smartly) advance the Miller blade, continually following what you see, and engaging the epiglottis when it is encountered, then lifting up to reveal the cords. In fact, several of the airway adjuncts presented at ACEP follow this same technique - with the video assist (which the expositors completely state) being an adjunct to manual - if you bury it in the esophagus initially, you negate the adjunct, whereas, if you do the technique correctly (advance at a regular pace) and then look at the screen as the camera gets there (or the Levitan intubating stylet), you see the cords directly on the way in, not pulling out.

I appreciate your experience, but you may be influencing newer personnel with what you know presented as law.

 

[12R34Y]

We've never discussed where you did paramedic school, but this is ABSOLUTELY the opposite of what I was taught (at 2 different schools, one for EMT-I, and one for EMT-P). Absolutely the opposite of what you assert as law (which I cannot find 100% justification for - in fact, I only find 1 source on a straw poll of Google that advocates what you say, whereas the others support how I was taught), the manner in which I was instructed was a "progressive laryngoscopy" - to deliberately (but smartly) advance the Miller blade, continually following what you see, and engaging the epiglottis when it is encountered, then lifting up to reveal the cords. In fact, several of the airway adjuncts presented at ACEP follow this same technique - with the video assist (which the expositors completely state) being an adjunct to manual - if you bury it in the esophagus initially, you negate the adjunct, whereas, if you do the technique correctly (advance at a regular pace) and then look at the screen as the camera gets there (or the Levitan intubating stylet), you see the cords directly on the way in, not pulling out.

I appreciate your experience, but you may be influencing newer personnel with what you know presented as law.

I also learned the way you are talking about apollyon.

However, I do know many who still ram it in and then "if you don't see anything familiar start backing up."

later

 

[southerndoc]

We've never discussed where you did paramedic school, but this is ABSOLUTELY the opposite of what I was taught (at 2 different schools, one for EMT-I, and one for EMT-P). Absolutely the opposite of what you assert as law (which I cannot find 100% justification for - in fact, I only find 1 source on a straw poll of Google that advocates what you say, whereas the others support how I was taught), the manner in which I was instructed was a "progressive laryngoscopy" - to deliberately (but smartly) advance the Miller blade, continually following what you see, and engaging the epiglottis when it is encountered, then lifting up to reveal the cords. In fact, several of the airway adjuncts presented at ACEP follow this same technique - with the video assist (which the expositors completely state) being an adjunct to manual - if you bury it in the esophagus initially, you negate the adjunct, whereas, if you do the technique correctly (advance at a regular pace) and then look at the screen as the camera gets there (or the Levitan intubating stylet), you see the cords directly on the way in, not pulling out.

I appreciate your experience, but you may be influencing newer personnel with what you know presented as law.

You've never attended The Airway Course by Ron Walls, have you? Walls is considered by many emergency physicians to be the king of emergent airway management.

"Once the blade has been correctly positioned adjacent to the right mandibular molar teeth, its entire length is passed blindly and atraumatically into the patient's esophagus, traversing the base of the tongue, passing posterior to the epiglottis and cords, anterior to the posterior pharyngeal wall, and finally moving superiorly and anteriorly through the cervical esophagus into the proximal body of the esophagus. Active visualization of the posterior pharyngeal or laryngeal anatomy is neither possible nor required during this initial maneuver. As mentione dpreviously, the esophageal insertion is done completely by feel, with gentle pressure exerted by the volar pads of the fingers and thumb allowing the laryngoscopist to feel the advancing tip of the laryngoscopic blade. The tip of the advancing blade should move toward the midline during this insertion. The laryngoscopist can be assured that the application of cricoid pressure may need to be eased slightly to effect a complete atraumatic insertion."

"How is esophageal placement of the blade beneficial to the laryngoscopist? With this initial position established, the cords will always be proximal to the tip of the laryngoscope blade, never distal. In emergent laryngoscopy this is of paramount importance. If the visual stage of laryngoscopy is begun without passing the entire blade into the esophagus, the proximal position of the cords in relationship to the tip of the blade cannot be ensured, thus increasing the likelihood of not recognizing what is initially visualized and prompting the dreaded questions, 'Where am I? Are the cords distal or more proximal? Do I need to go deeper or come out more?' and the dance begins, frantically inserting and withdrawing the blade in search of the glottis, each time producing more laryngeal trauma and operator anxiety."

Walls, RM. Manual of Emergency Airway Management. Lippincott, Williams, and Wilkins, 2004: 58.

This is the way I was taught in paramedic school and the way I was taught by several anesthesiologists during my anesthesia rotation.

I'm not sure about your Google skills, but I found:

"The straight Miller blade is inserted deep into the oropharynx, PAST the epiglottis. Providing sufficient lifting force in parallel with the handle, yet avoiding posterior rotation that causes the blade to press against the teeth, under direct vision, the blade is slowly withdrawn. It will slip over the anterior larynx and come to a position at which it holds the epiglottis flat against the tongue and anterior pharynx, exposing a view of the larynx." http://www.healthsystem.virginia.edu/Internet/Anesthesiology-Elective/airway/Intubation.cfm

"Paraglossal technique: slide Miller 3 blade along alveolar ridge and insert to hilt (purposefully insertingit down esophagus); lift and pull back slowly; airway will drop into view with palpable thud; if pull out too quickly and epiglottis drops in way, use straight blade to move it; high success rate" http://www.audio-digest.org/cgi-bin/htmlos/0478.25.5571170329082068641/EM2110

 

[greytmedic]

There are many different techniques out there that will allow for the visualization of the vocal cords. One of the most important ways in selecting a technique that works for you is experience. Everybody has a slight variation that they think works the best, whether it is the type of blade used, the way the blade is place, to just hyperextend (non-traumatic pt) the neck or move the pt's head off cot/backboard/bed so it is hanging down, or the exact position of the blade. Once you have some more training and experience you will develop your own style that works for you. Just make sure you are not harming the pt. It really doen't matter what technique you use, the most important aspect of intubation is recognizing a misplaced tube. It happens to everybody, just make sure that you visualize the tube pass through the cords and use all assessment knowlege you have to guarantee you have the tube in the right place. Once you have training and get to perform your new skill on a call, just re-evaluate your call with your partners and make notes on what worked and what did not and adjust from there. Always remember, you "practice" medicine so you can always get better.

 

[Apollyon]

I'm not sure about your Google skills, but I found:

"The straight Miller blade is inserted deep into the oropharynx, PAST the epiglottis. Providing sufficient lifting force in parallel with the handle, yet avoiding posterior rotation that causes the blade to press against the teeth, under direct vision, the blade is slowly withdrawn. It will slip over the anterior larynx and come to a position at which it holds the epiglottis flat against the tongue and anterior pharynx, exposing a view of the larynx." http://www.healthsystem.virginia.edu/Internet/Anesthesiology-Elective/airway/Intubation.cfm

Notwithstanding your condescension about my "Google skills" and about not having attended Ron Walls' course (sorry that I and my program don't have the money), but the citation above was the only one I found on the first page that supported the manner that you exposited. Moreover, on my anesthesia rotation, no one - not a one - of the anesthesia attendings at Duke taught the way you are expounding.

Now, I don't know about you, but, when I was prehospital, I had never heard of Ron Walls. Moreover, what did you do before you were an EM resident? Ron Walls may be "king" (he did give a very good and very EM-biased talk on airway failures at ACEP), but not everyone is able to get a command performance with royalty, and there are more paramedics and EMT-I's getting trained to perform ETI than there are people at Harvard doing EM or going to ACEP. I don't even know how many non-docs went to ACEP, and I don't know if Dr. Walls does prehospital lectures.

Good BLS is better than bad ALS, and, of all the people I've EVER tubed, the one questionable tube that had 2 EM-2's going against me (and a partner that stabbed me in the back) STILL had an attending that took my side AGAINST the residents, backing me up when the residents were saying that I had tubed the esophagus and that, with the balloon inflated, with a sat of 96%, vomitus in the oropharynx, a clear chest xray, and no vomit in the tube, that the patient was being ventilated into the esophagus, around the tube, retrograde to the carian, and thence into the trachea. I used a Miller 3 on that patient, by going in the way I knew, and, if the tube dislodged, it was in the 30 or so meters from the back of the ambulance into the room at Buffalo General. The patient lived, by the way, with no sequel.

Why I say "good BLS is better than bad ALS" is that, if you can bag, go with it, until you can secure the airway.

My final thought is that your impugning of anything that is not done your way is not completely valid, since most of the paramedics I know were taught the way I was, and they hit most of their tubes - so, if it works, it works. You imply that your way is the only way, and I say that I disagree. As far as esophageal perf, I saw that once by a primary care doc that tried to tube a patient with a stylet that protruded beyond the end of the ET tube. Not pretty.

 

[Apollyon]

There are many different techniques out there that will allow for the visualization of the vocal cords. One of the most important ways in selecting a technique that works for you is experience. Everybody has a slight variation that they think works the best, whether it is the type of blade used, the way the blade is place, to just hyperextend (non-traumatic pt) the neck or move the pt's head off cot/backboard/bed so it is hanging down, or the exact position of the blade. Once you have some more training and experience you will develop your own style that works for you. Just make sure you are not harming the pt. It really doen't matter what technique you use, the most important aspect of intubation is recognizing a misplaced tube. It happens to everybody, just make sure that you visualize the tube pass through the cords and use all assessment knowlege you have to guarantee you have the tube in the right place. Once you have training and get to perform your new skill on a call, just re-evaluate your call with your partners and make notes on what worked and what did not and adjust from there. Always remember, you "practice" medicine so you can always get better.

I was typing as your post was posted. I concur 100%.

 

[southerndoc]

Notwithstanding your condescension about my "Google skills" and about not having attended Ron Walls' course (sorry that I and my program don't have the money), but the citation above was the only one I found on the first page that supported the manner that you exposited. Moreover, on my anesthesia rotation, no one - not a one - of the anesthesia attendings at Duke taught the way you are expounding.

Oddly enough, I got the feeling of condescension from your first post.

Now, I don't know about you, but, when I was prehospital, I had never heard of Ron Walls. Moreover, what did you do before you were an EM resident? Ron Walls may be "king" (he did give a very good and very EM-biased talk on airway failures at ACEP), but not everyone is able to get a command performance with royalty, and there are more paramedics and EMT-I's getting trained to perform ETI than there are people at Harvard doing EM or going to ACEP. I don't even know how many non-docs went to ACEP, and I don't know if Dr. Walls does prehospital lectures.

I was taught to do the technique as I described previously. It was taught to me by the anesthesiologist who taught the airway component of our paramedic class. I wasn't trained on intubation as an EMT-I (Georgia doesn't allow it), so I cannot comment on that.

For the most part, most people are taught "insert the blade, lift the epiglottis directly" without actually being instructed on the technique itself.

Good BLS is better than bad ALS, and, of all the people I've EVER tubed, the one questionable tube that had 2 EM-2's going against me (and a partner that stabbed me in the back) STILL had an attending that took my side AGAINST the residents, backing me up when the residents were saying that I had tubed the esophagus and that, with the balloon inflated, with a sat of 96%, vomitus in the oropharynx, a clear chest xray, and no vomit in the tube, that the patient was being ventilated into the esophagus, around the tube, retrograde to the carian, and thence into the trachea. I used a Miller 3 on that patient, by going in the way I knew, and, if the tube dislodged, it was in the 30 or so meters from the back of the ambulance into the room at Buffalo General. The patient lived, by the way, with no sequel.

Why I say "good BLS is better than bad ALS" is that, if you can bag, go with it, until you can secure the airway.

This wasn't a debate over proper placement of tubes, but better visualization techniques. We've all had our share of esophageal intubations, but it's unrecognized esophageal intubations that are the problem. I agree, BLS skills are important and supercede ALS skills.

My final thought is that your impugning of anything that is not done your way is not completely valid, since most of the paramedics I know were taught the way I was, and they hit most of their tubes - so, if it works, it works. You imply that your way is the only way, and I say that I disagree. As far as esophageal perf, I saw that once by a primary care doc that tried to tube a patient with a stylet that protruded beyond the end of the ET tube. Not pretty.

I do not imply that my way is the only way. I'm sure your experience with how pre-hospital providers are taught is limited to the NY and NC areas, as mine is limited to the GA, SC, and CT areas. So what you're familiar with teaching-wise isn't what I'm familiar with.

It has been deemed the "correct" way by experts with far more experience than either you or me. I tend to respect those peoples' teachings because their experience has led them to teaching the way they do. Ron Walls has a valid point: I have seen many residents waste a lot of time moving the laryngoscope in and out trying to find the epiglottis.

 

[Apollyon]

Oddly enough, I got the feeling of condescension from your first post.

Not intended. Apologies.

It has been deemed the "correct" way by experts with far more experience than either you or me. I tend to respect those peoples' teachings because their experience has led them to teaching the way they do. Ron Walls has a valid point: I have seen many residents waste a lot of time moving the laryngoscope in and out trying to find the epiglottis.

Fair enough.

 

[southerndoc]

Not intended. Apologies.

My apologies as well.

 

[jetproppilot]

Macs do cause less trauma than Miller blades. There have been several cases reported of esophageal perforation from Miller blades. Just think about it. The correct technique is to blindly insert the Miller all the way in, lift up, and pull back until you see the vocal cords (or the epiglottis fall down, at which point you readvance and lift up the epiglottis directly). Pulling up on the blade while it's in the esophagus is setting up for an esophageal perforation.

Sorry, I repectfully disagree.

Citing "several" case reports implying the Mac is a superior-less-trauma-causing blade is misleading. If that were the case, a "standard of care" would be established, and a clinician would be "forced" to use a Mac as a first line blade.

Also disagree with your citing the "proper technique" of using a Miller. Yes, I remember hearing your quoted technique...but to cite it as "proper" implies that inserting a Miller any other way is "improper."

I'm a private-practice anesthesiologist, and almost exclusively use a Miller 2. Not saying a Miller is better than a Mac. Thats for the clinician to decide. After intubating many, many, many people, a clinician no longer has to "bury" the Miller 2. The blade becomes an extension of your hand, and 99.9% of the time, the amount of blade inserted for said patient is nearly perfect.

Again, I prefer the Miller. But the chairman of my residency program, a Brit, (I finished in 1996) used a Mac 3 EXCLUSIVELY. Dude could intubate an ant with a Mac 3.

And I feel just as confident with a Miller 2.

Intubating-blade preference has alot to do with what you prefer, and what you've grown to use, hence intubating many people with it (in an anesthesiologists book, thousands) , which in turn enhances your prowess.

Used correctly, any blade can be gentle on glottic tissue. Used incorrectly, any blade can be traumatic to glottic tissue.

Intubation skill is one of the more operator-dependent procedures in medicine....watch a gifted laryngoscopist, and every move is gentle and orchestrated...watching a novice will make any anesthesiologist cringe....independent of selected-blade.

 

[southerndoc]

Sorry, I repectfully disagree.

Citing "several" case reports implying the Mac is a superior-less-trauma-causing blade is misleading. If that were the case, a "standard of care" would be established, and a clinician would be "forced" to use a Mac as a first line blade.

Also disagree with your citing the "proper technique" of using a Miller. Yes, I remember hearing your quoted technique...but to cite it as "proper" implies that inserting a Miller any other way is "improper."

I'm a private-practice anesthesiologist, and almost exclusively use a Miller 2. Not saying a Miller is better than a Mac. Thats for the clinician to decide. After intubating many, many, many people, a clinician no longer has to "bury" the Miller 2. The blade becomes an extension of your hand, and 99.9% of the time, the amount of blade inserted for said patient is nearly perfect.

Again, I prefer the Miller. But the chairman of my residency program, a Brit, (I finished in 1996) used a Mac 3 EXCLUSIVELY. Dude could intubate an ant with a Mac 3.

And I feel just as confident with a Miller 2.

Intubating-blade preference has alot to do with what you prefer, and what you've grown to use, hence intubating many people with it (in an anesthesiologists book, thousands) , which in turn enhances your prowess.

Used correctly, any blade can be gentle on glottic tissue. Used incorrectly, any blade can be traumatic to glottic tissue.

Intubation skill is one of the more operator-dependent procedures in medicine....watch a gifted laryngoscopist, and every move is gentle and orchestrated...watching a novice will make any anesthesiologist cringe....independent of selected-blade.

I'm sure you have intubated many more people than most emergency physicians, including Ron Walls himself. I respect your views.

The case reports of esophageal perforations secondary to intubation was recently reviewed at my facility after an intubation attempt resulted in an esophageal perforation. One of our anesthesia attendings, who was present for the review, brought forward that most of these case reports were presented after failed intubation attempts with Miller blades. Was I premature in drawing the conclusion? Perhaps. A definite cause-effect relationship wasn't evaluated, so who knows.

At what point do you think it's reasonable to not "bury" the Miller? I've intubated more than 100 patients (a very low number compared to you I'm sure), and I still bury the Miller when I intubate. It's the way I was taught. I have not developed the skill of knowing the "exact spot" to place the Miller, like I have developed with the Mac. I may never develop this sense with the Miller since I almost always intubate with the Mac and since I adhere to the method described by Walls, et al. I'm not going to chance it either. All of my intubations, minus my brief OR rotation that resulted in about 30 intubations, are done emergently, where I do not want to do the "dance" that Walls describes.

 

[jetproppilot]

I'm sure you have intubated many more people than most emergency physicians, including Ron Walls himself. I respect your views.

The case reports of esophageal perforations secondary to intubation was recently reviewed at my facility after an intubation attempt resulted in an esophageal perforation. One of our anesthesia attendings, who was present for the review, brought forward that most of these case reports were presented after failed intubation attempts with Miller blades. Was I premature in drawing the conclusion? Perhaps. A definite cause-effect relationship wasn't evaluated, so who knows.

At what point do you think it's reasonable to not "bury" the Miller? I've intubated more than 100 patients (a very low number compared to you I'm sure), and I still bury the Miller when I intubate. It's the way I was taught. I have not developed the skill of knowing the "exact spot" to place the Miller, like I have developed with the Mac. I may never develop this sense with the Miller since I almost always intubate with the Mac and since I adhere to the method described by Walls, et al. I'm not going to chance it either. All of my intubations, minus my brief OR rotation that resulted in about 30 intubations, are done emergently, where I do not want to do the "dance" that Walls describes.

certainly not implying that what you do, intubation wise, is incorrect...far from it....just concerned that readers may take away from said posts that a Mac blade is somehow intrinsically "safer", which in my humble opinion, it is not.

Anyway, heres probably the best trick I know of, regardless of which blade you are using.....

Left hand is holding the handle....eyes looking down the dude's throat....dont see what you need to see right away?????

Take your right hand, grasp near the dude-you-are-intubating's-adam's apple (like you are applying cricoid pressure), push down. Still dont see it? Wiggle it from left to right.

Sounds silly, but this is probably one of the most common tricks-of-the-trade used by anesthesia providers. I see it used everyday, either by myself or someone else. You are essentially moving the anatomy left or right until you can see it.

Heres another way of looking at it, Sir. Dont use the Miller blindly. You can follow a visual path, after good head extension, in 95% of patients, from posterior tongue, insert a little more, and theres the tip of the epiglottis...again, most of the time after inserting the Miller 2 to the base-of-the-tongue-depth, one can approximate how much more to "exactly" insert it before lifting up......
....but hey, thats splitting hairs on technique. I think a clinician should use whatever technique they are most comfortable with, and use which blade they're most comfortable with.

Just think its wrong for a clinician to attach his name to the "correct way" to do something (sorry, I've been in private practice for ten years and I dont know who Dr Walls is), when in fact, there may be other techniques and "tweaks" available.

Just my 2 cents. Dont let someone convince you one blade is better than the other, or that one technique is better than the other. Learn the tricks-of-the-trade for each blade, use both of them alot, then YOU decide which is better. And better means you dont miss, with rare exception.

If I were teaching ANYONE intubating tricks, heres the TOP FIVE:

1)For a Mac blade, put a pillow under pts head. Maximize head flexion. The head more anterior assists laryngeal-pharyngeal allignment. Yes, its a little harder to get the blade in, but once you hit the vallecular space, the glottis is usually looking up at you. Usually the bed lower than normal will help you. To give you a visual, for difficult airways during my residency, Dr Grogono would put the OR bed as low as possible, raise the head as high as possible with pillows (sometimes the pts chin would be literally touching their chest), then he'd work for 10-15 seconds to get the Mac3 in.....I NEVER saw him miss. Not one time. Again, this is what he was comfortable with, and he knew how to optimize the intubation environment for his selected blade.

2)For Miller blades, pillows are a hindrance. Remove the pillow. Maximize head extension. Best case scenerio is a shoulder roll. So if you are anticipating difficulty, put a shoulder roll in. Open the mouth, let the tip of the blade touch the posterior pharynx while applying some inferior pressure on the tongue. Now, concominantly, take a stance like you see on ER when Anthony Edwards is intubating whilst inserting the Miller about another inch. If you dont see cords you can usually see what you need to see to adjust your blade direction.

3)The right-hand-move-the-larynx-from-side-to-side-while-pushing-down-at-the-same-time is probably the biggest trick used by anesthesia providers.

4)HAVE A BOUGIE AVAILABLE....or whatever your institution calls the long,orange-stylette-thinghy with an angled,somewhat angulated tip. If you see just the bottom of the cords and cant quite get the styletted ETT in, no need to kill yourself. Stick the bougie in...but heres the trick....DONT PULL OUT YOUR BLADE JUST YET. Keep it where youve got it and have an assistant slide the tube over the bougie. Sometimes, if you pull your blade, even if the bougie is through the cords, the ETT wont follow it and wont pass the cords.

5) Looked a cuppla times and dont see anything you need to see? LET A COLLEAGUE (if available) LOOK. Even anesthesiologists have bad days with airways....dont be proud. Call for help if you need it.

There you have it. Jet's TOP FIVE intubating tricks-of-the-trade.

Hope they help you someday.

 

[southerndoc]

Thanks for the tips. The technique you describe seems similar to the BURP technique that is taught to emergency medicine physicians. BURP is Backwards, Up, to the Right, and with Pressure. It does help with visualization of the cords, but if you are using the Miller blade with the technique advocated by Walls, et al., then you should ease up on the pressure while the blade is being inserted.

We just recently got bougies in our ED. I haven't had the chance (or need) to use one yet. Our anesthesiologists love them. In fact, when they respond to codes and in-hospital intubations, they have one attached to their airway bag.

For the record, the method described by Walls, et al. (and the anesthesiologists who supervised me during my OR rotations) do not call it the Walls technique.

 

[jetproppilot]

Thanks for the tips. The technique you describe seems similar to the BURP technique that is taught to emergency medicine physicians. BURP is Backwards, Up, to the Right, and with Pressure. It does help with visualization of the cords, but if you are using the Miller blade with the technique advocated by Walls, et al., then you should ease up on the pressure while the blade is being inserted.

We just recently got bougies in our ED. I haven't had the chance (or need) to use one yet. Our anesthesiologists love them. In fact, when they respond to codes and in-hospital intubations, they have one attached to their airway bag.

For the record, the method described by Walls, et al. (and the anesthesiologists who supervised me during my OR rotations) do not call it the Walls technique.

Seems like we'd all be better off if our literature was not so specialty-specific...and this is a lesson for me as well...look beyond your specialty for advice.

Hmmmm.....BURP. Thats awesome.

 

[jetproppilot]

Thanks for the tips. The technique you describe seems similar to the BURP technique that is taught to emergency medicine physicians. BURP is Backwards, Up, to the Right, and with Pressure. It does help with visualization of the cords, but if you are using the Miller blade with the technique advocated by Walls, et al., then you should ease up on the pressure while the blade is being inserted.

We just recently got bougies in our ED. I haven't had the chance (or need) to use one yet. Our anesthesiologists love them. In fact, when they respond to codes and in-hospital intubations, they have one attached to their airway bag.

For the record, the method described by Walls, et al. (and the anesthesiologists who supervised me during my OR rotations) do not call it the Walls technique.

just an addendum, Southern, I was a firefighter/paramedic before I went the college/med-school/residency route...and I moonlighted as an ER doc 72 hours a month (2 twelve-hour shifts per weekend, three weekends a month) during my entire residency...so I appreciate how hard it is for a paramedic to intubate coded-dude-in-Winn Dixie-on the floor-by-the-lettuce, or ER doc-intubating-250 lb-dude-who-ate-at-Burger King-30 minutes ago. Not "optimized" conditions by any stretch of the imagination.

You guys need every trick known to man in your armementarium in order to be successful at getting-the-tube-in.

 

[FoughtFyr]

As I understand it, the "bury the hub" technique of the miller blade was the original method "as designed". This led to the few medics out there, like myself, told to use a miller 4 for nearly everything because you could always use less blade but you couldn't lengthen one that was too short. It also led to perfs, both trach and esophageal - but was quick and easy to learn/teach.

However, progressive largynoscopy became a often used anesthesia trick. More positive control of the epiglottis and all. However the horse blade is rarely use, most, like Jetproppilot, use a miller 2.

So in short, you are both right.

BTW - no net sources, just the anesthesia folks here.

- H

 

[jetproppilot]

It has been deemed the "correct" way by experts with far more experience than either you or me. .

Sadly, it appears the "experts" did not consult with clinicians that manage airways for a living.

 

[Apollyon]

However, progressive largynoscopy became an often used anesthesia trick. More positive control of the epiglottis and all. However the horse blade is rarely used, most, like Jetproppilot, use a miller 2.

So I'm NOT crazy? Even so, I use a Miller 3.

So in short, you are both right.

Me and southerndoc, or SD and jetproppilot?

 

[southerndoc]

Sadly, it appears the "experts" did not consult with clinicians that manage airways for a living.

Actually, three of the people who taught this were anesthesiologists who intubate for a living. One during my paramedic class, two during residency. There are only two anesthesiologists as contributing editors for the Manual of Emergency Airway Management.

 

[southerndoc]

So I'm NOT crazy? Even so, I use a Miller 3.

Well, you're still crazy -- emotionally that is! Just kidding, just kidding!

Me and southerndoc, or SD and jetproppilot?

Aren't you and jetproppilot advocating the same technique?

 

[Apollyon]

Well, you're still crazy -- emotionally that is! Just kidding, just kidding!



Aren't you and jetproppilot advocating the same technique?

As to the above post: all true. Agree.

 

[a_ditchdoc]

I was kind of surprised to see the anesthesiologists during my surgery rotation using exclusively mac blades. As a medic, during the first two years or so I would rotate between miller and mac, just to get a feel for them. Eventually I decided there was nothing I could not do with a miller that I could do with a mac. For ten years I used a miller, with maybe a few macs with collared patients or that partners had already set up. It just seems that with the miller I had more room to maneuver the tube around in people with difficult airways. The mac always seemed to get in the way.

When I first started using the miler, although it is not necessarily how I was taught (that I remember now anyway), I would put the blade all the way in and pull back until I felt a "Drop" as it came out of the esophagus. Usually the tip was right where it needed to be. As I gained more experience, eventually I just kind of "knew" where everything was supposed to be. I never made a conscious decision to stop pushing it all the way in.

As for the mac, shamefully I have used it once or twice to hold the epiglottis directly. Not a great idea I'm sure. Once I witnessed a tracheal perforation/false passage created by a mac used by a really gung-ho doc...it was not hard to see it coming. If you hear gristly sounds it may be best to let up on the pressure and stop forcing the tube...

I just don't get all these mac fans. Maybe I need to give'em another try...

 

[12R34Y]

I was kind of surprised to see the anesthesiologists during my surgery rotation using exclusively mac blades. As a medic, during the first two years or so I would rotate between miller and mac, just to get a feel for them. Eventually I decided there was nothing I could not do with a miller that I could do with a mac. For ten years I used a miller, with maybe a few macs with collared patients or that partners had already set up. It just seems that with the miller I had more room to maneuver the tube around in people with difficult airways. The mac always seemed to get in the way.

When I first started using the miler, although it is not necessarily how I was taught (that I remember now anyway), I would put the blade all the way in and pull back until I felt a "Drop" as it came out of the esophagus. Usually the tip was right where it needed to be. As I gained more experience, eventually I just kind of "knew" where everything was supposed to be. I never made a conscious decision to stop pushing it all the way in.

As for the mac, shamefully I have used it once or twice to hold the epiglottis directly. Not a great idea I'm sure. Once I witnessed a tracheal perforation/false passage created by a mac used by a really gung-ho doc...it was not hard to see it coming. If you hear gristly sounds it may be best to let up on the pressure and stop forcing the tube...

I just don't get all these mac fans. Maybe I need to give'em another try...

I still have to say that I love the MAC and almost exclusively use a MAC 3 (sometimes a 4). I like how the MAC controls the tongue more completely for me. Again.....I think the view created from the maC is awesome. Part of the view into the cords is obstructed simply by the fact that the miller is lifting up the epiglottis directly. just my own bias.

HOpefully during my anesthesia rotation next year during EM residency I'll be able to play some more with the millers and maybe I'll change my mind. doubt it, but you never know.

good disussion.

 

[southerndoc]

Changing the discussion a bit:

What blade do you guys prefer to use for trauma patients that are collared with their necks immobilized?

 

[jetproppilot]

I still have to say that I love the MAC and almost exclusively use a MAC 3 (sometimes a 4). I like how the MAC controls the tongue more completely for me. Again.....I think the view created from the maC is awesome. Part of the view into the cords is obstructed simply by the fact that the miller is lifting up the epiglottis directly. just my own bias.

HOpefully during my anesthesia rotation next year during EM residency I'll be able to play some more with the millers and maybe I'll change my mind. doubt it, but you never know.

good disussion.

Its good to keep an open mind. Back when I was a paramedic, I thought I was pretty good with a tube. Now that I've been outta anesthesia residency for almost ten years, with, hmmm...say, 5000-10,000 intubations later (left it broad, probably right in the middle of that), I wish, when I was a paramedic student, I had the opportunity to hook up with someone who does factory-line-like intubating. Again, not trying to boast here; prowess with a skill...intubations, central lines, arterial lines, laparoscopic gallbladders, bowel resections....relies heavily on REPETITION. Thats why doctors do residencies....for exposure...

and I GUARANTEE a skilled clinician in any field...anesthesia, heart surgery, general surgery...could take a bright-high school graduate and apprentice them through the various moves of said specialty...how to position a wrist and angle the Arrow for an arterial line, how to open a chest, how to close a belly....and said-high school graduate, if he worked with the skilled-clinician for enough cases, would become proficient at putting in an art line, opening a sternum, or closing a belly.

There are institutions in this country whose heart surgeons rely heavily on the PAs in their group...and some of those PAs are just as good as most heart surgeons at a certain skill...certainly not the tertiary thinking necessary to problem solve when things go awry, and certainly not identifying target-areas for distal anastomoses (which is where the money's at) and tying in the distals...but point being, paraprofessionals can be taught, and become very proficient at, certain skills.

One of the raves in heart surgery today is endoscopic-saphenous vein harvest. Wanna know who the leader in this technique is? A surgical tech named Johnny...worked with him and the group of heart surgeons he worked for for years. He is in the educational video disseminated throughout the US. He can endoscopically harvest a saphenous vein in 15-20 minutes...I've yet to see, after nearly ten years of private practice, any MD duplicate his skill.

So back to the refining-a-certain-skill-theme...no matter who you are, and what your level of training is, if you are trying to perfect a certain skill,

look to the group of people that have done said skill thousands of times. They know how to do it better than anyone else.

 

[12R34Y]

Changing the discussion a bit:

What blade do you guys prefer to use for trauma patients that are collared with their necks immobilized?

I know the way I was taught back in the day in paramedic school that you typically use a straight blade for trauma patients in c-collars.

I however, am more comfortable with a curved MAC and thus thought it ridiculous to suddenly force me to use a blade I'm not nearly as comfortable with to control and airway that is probably going to be more challenging (ie trauma patient in c-collar).

Of course i always had the collar removed and someone hold in-line traction, but still.

I used the MAC3 just fine on traumas. again just little 'ole me and what I used to do.

curious as to what others do.

later

 

[jetproppilot]

I know the way I was taught back in the day in paramedic school that you typically use a straight blade for trauma patients in c-collars.

I however, am more comfortable with a curved MAC and thus thought it ridiculous to suddenly force me to use a blade I'm not nearly as comfortable with to control and airway that is probably going to be more challenging (ie trauma patient in c-collar).

Of course i always had the collar removed and someone hold in-line traction, but still.

I used the MAC3 just fine on traumas. again just little 'ole me and what I used to do.

curious as to what others do.

later

Nice post.

And I'm gonna be frank here.

Anesthesiologists, simply by the nature of their trade, are the airway-gods on this planet. Just like the heart-surgeons are the heart surgery gods, the ER docs are the ER gods, the paramedics are the paramedic gods, etc etc.

So take it from an anesthesiologist.

There is no written word in the anesthesia literature, anywhere, that a Miller blade is superior for trauma patients in C collars, to the point that a standard of care has been established.

Heres what I've learned after ten years in medicine. Reports will be published. Cases will be published. Techniques will be published as "the right way".

Take an isolated study, or even a group of studies, and proclaim them as standard-of-care, without an intricate knowledge of the subject, and you may be fooling yourself. And everyone else that you disseminate the info to.

Heres an example. Beta blockers, in general, used to come with the package-insert that said contraindicated for CHF patients. Geez, funny now that the same package inserts say indicated for CHF patients. The true experts probably laughed at the previous "contraindicated" disclaimer...since they knew differently.

Science changes over time. And even in "current day", there are many ways to skin-a-cat for most things in medicine.

One report/study/case report, or "knowing" anesthesiologists/ER docs etc that do something a certain way does not mean its the "right" way. A "way"? Absolutely. THE way? Absolutely not, unless a standard-of-care has been established.

It takes overwhelming, replicated data in order to establish something as "standard of care". And even then, said standard of care may change. Look at the current literature on the relevance of ALS pre-hospital airway management, and it's influence on patient survival.

SO, when you read, from an "expert", that you should use a Miller blade in immobilized patients,

look at the literature closely. Who's the expert proclaiming this? What is his/her experience level with said procedure? Are the scientific methods in said study intact? Is it a multi-center study? Is it randomized? Is the n value high enough, and the p value low enough, in combination with all other appropriate scientific-methods, to warrant a clinician changing his/her clinical practice?

Maybe.

And maybe not.

To date, I'm not aware of any overwhelming literature proclaiming a straight blade superior when intubating the spinally immobilized patient.

I'd keep using whatever blade you are most comfortable with.

And I'd take proclaimed "right ways" to do things with a grain of salt, if you are an expert in said field, and you disagree with the proclaimed "right way".

 

[a_ditchdoc]

A collared patient is one of the few times I would try a mac. With the miller my technique was to hyperextend the neck. Without this, I just couldn't get a view of the cords. The mac seems to take less repositioning of the patient...

 

[12R34Y]

A collared patient is one of the few times I would try a mac. With the miller my technique was to hyperextend the neck. Without this, I just couldn't get a view of the cords. The mac seems to take less repositioning of the patient...

also agree.

later

 

[rn29306]

I've managed to successfully intubate most all collared patients with a Mac.
At our facility, the collar is removed and someone from anesthesia holds in-line traction. There was one incident in which a patient had a known cervical fx and the CRNA told the MD she didn't want to do the intubation. He used a Miller 2. I came into the room just as he was about to intubate and there was no movement of the neck.

It's like its been stated before. There are all kinds of 'suggestions', but a precedent or standard of care has not been established. If you can personally drop a tube with no neck movement with a Mac, then that's the blade for you. Switching to something you are less familiar with when a potentially dangerous situation presents itself is not the time to change variables. Go with what you know.

 

[Lexems118]

I have yet to intubate a real person but have learned how to use the combi-tube, so should be interesting