Any utility in learning Miller blade over Mac

[flightdoc09]

EM resident here on my airway rotation. Haven't missed a single airway with the Mac blade. Today the CRNA had already opened a Miller and made me use it. I haven't used one in several years since when I was a med student, and I was having a lot of difficulty with positioning, getting under the epiglottis, controlling the tongue, etc. Still had plenty of preoxygenation, but decided to hand it back to the CRNA before I caused any additional airway trauma besides a little abrasion I caused in the posterior pharynx.

Anyways, my question is, is there any utility in learning the Miller blade if I'm really good with the Mac? Or just keep getting better with the Mac?

I know there's always the hypothetical scenario where that's all I have, but everywhere I've rotated they always have more Mac blades in the airway carts, and many don't even have Millers in the ED.

Thanks

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[clibby]

Try it during residency so you know how it is used. However, I am a fan of learn one method really well, have your backup methods, and know who you can call for help. We will never intubate as much as anesthesia so we will never be experts at all the ways to intubate. If you get 150 intubations during residency, do you want to split that up between Mac, Miller, and Glidescope or learn either Mac or Miller in addition to glidescope? (You have to learn one way to DL and VDL). I like the mac blade because you can use video larangoscopy with Mac blades which is helpful when the camera gets covered in blood/vomit. However, I do encourage you to get as much experience with peds as you can. I thought I would be a Mac guy with kids too, but no. Miller in kids is just easier for me and I needed to try both to figure that out.

 

[emergentmd]

In 20 yrs, I use a Mac 4 and never needed a miller or a smaller blade unless it was pediatric. Tried miller early on but Mac was just easier for me and more ubiquitous. Mac 4 + Bougie never failed me even if I could not see the cords.

 

[Groove]

EM resident here on my airway rotation. Haven't missed a single airway with the Mac blade. Today the CRNA had already opened a Miller and made me use it. I haven't used one in several years since when I was a med student, and I was having a lot of difficulty with positioning, getting under the epiglottis, controlling the tongue, etc. Still had plenty of preoxygenation, but decided to hand it back to the CRNA before I caused any additional airway trauma besides a little abrasion I caused in the posterior pharynx.

Anyways, my question is, is there any utility in learning the Miller blade if I'm really good with the Mac? Or just keep getting better with the Mac?

I know there's always the hypothetical scenario where that's all I have, but everywhere I've rotated they always have more Mac blades in the airway carts, and many don't even have Millers in the ED.

Thanks

Identical practice to @emergentmd . I use miller for 100% peds. It was good practice in residency (you should always challenge yourself and my attendings would ask me what blade I wanted and then purposefully give me something else, etc..) However, I'm almost solely Mac 4 as an attending and almost never reach for anything else. The beauty of the 4 blade is that it can provide such a great view and is long enough that you can lift up the epiglottis and use it like you would a miller. The occasional hairy airway is usually easily navigated with a Mac 4 + bougie. Now that I think about it...the Mac 4 approach was sold to me by one of my ICU attendings in residency. That guy had these gorilla arms and I remember always thinking he was going to rip their jaw out of their head. The entire head and torso would damn near come off the table when he would lift the blade handle, lol.

I'll usually challenge some of my residents on occasion to try different blades but most of the time I'm simply trying to challenge them to use DL since everybody and their grandmother seems to be 100% VL these days. I feel like an old dinosaur lamenting the death of "DL finesse". I can still remember my anesthesia boarded PD grumbling when we'd reach for the glidescope "What are you gonna do when the light or screen goes out?! Put that thing away!" I don't think he foresaw how the glidescope and VL would take the world by storm and is probably standard of care at this point. Still though...I find myself channeling my old PD sometimes "What ya gonna do when they call you to CT to tube someone and your partner has the glidescope?! Hrrrmph! Put that thing away!" lol

 

[Rekt]

You can MAC peds. Miller only will be the next thing to go by the wayside. With exception of neonates for now.

I personally can't stand almost every crna I've met, but the only one crna that used MAC on one of my gas rotations said "There's a reason MAC was invented after Miller". CRNAs are cult like with using the miller to "feel superior" to you. Stick with a Mac.

 

[emergentmd]

Identical practice to @emergentmd . I use miller for 100% peds. It was good practice in residency (you should always challenge yourself and my attendings would ask me what blade I wanted and then purposefully give me something else, etc..) However, I'm almost solely Mac 4 as an attending and almost never reach for anything else. The beauty of the 4 blade is that it can provide such a great view and is long enough that you can lift up the epiglottis and use it like you would a miller. The occasional hairy airway is usually easily navigated with a Mac 4 + bougie. Now that I think about it...the Mac 4 approach was sold to me by one of my ICU attendings in residency. That guy had these gorilla arms and I remember always thinking he was going to rip their jaw out of their head. The entire head and torso would damn near come off the table when he would lift the blade handle, lol.

I really do not understand learning all the blades. I used miller, all the sizes, VL throughout my career. But I can't remember a time when Mac 4+Bougie failed and VL/miller saved me. I had prob 2 in my whole career that I could not get it with a Mac 4 and the Anesthesiologist told me it was hard so he used a Bougie. Well, now I just go straight to having a Bougie next to me.

Never needed a miller. Young docs prob think i am crazy not doing VL but why do I need VL when a Mac 4/Bougie never fails.

To think about it, I never used US to do a Central line either and can't think of a time where I missed one. I had a young buck using U/S spend an hr trying to put a CL in and came out asking me for help. I just felt for landmarks, and did one in 10 min.

 

[RustedFox]

"I had a young buck using U/S spend an hr trying to put a CL in and came out asking me for help. I just felt for landmarks, and did one in 10 min."


Its because they don't go superiorly enough in the triangle (in general).

 

[Arch Guillotti]

a Mac 4/Bougie never fails.

🙄😳🙂

 

[coffeebythelake]

🙄😳🙂

Yeah exactly

 

[HoosierdaddyO]

I don’t know… I feel like why do something like mac/Miller, or a central line blind… when there are other literature proven methods that increase success and less complications?! I get old habits die hard and if it works for you awesome… but we can agree that it’s no longer standard of care 🙂. Granted if WW3 breaks out and there are power outages everywhere not allowing us to us U/S or VL, but I feel like we will have bigger issues if that’s the case lol.

 

[Apollyon]

You want to define "hubris"? "Never fails" and "Always works".

 

[EctopicFetus]

I did my resident research on airways. Played with a bunch of toys. I’ll play devils advocate as someone who is 10+ years out of training. Mac is way better but it is worth learning Miller. Saved me once. But still saved me. I am a huge proponent of vdl. That’s my go to. It’s like a cheat code in a video game. Airways shouldn’t be a 5/10 hard (normal dl) when it could be a 1/10 with vdl. I think learning to place central lines blindly is a worthwhile endeavor as there are some places without us. I learned it this way but use us most of the time. How little residents understand the anatomy and landmarks is sad since they fully rely on us.
my single case where Miller saved me. Guy who doesn’t speak English comes to my solo coverage Ed around midnight. Clear upper airway issue struggling to breath, starts pouring blood out of his mouth. nurse Tells me he has been in our system. A quick review is that this guy has some cancer in his mouth,seen by ent. Long story short I struggle to intubate the guy, video doesn’t help as I suction a canister full of blood and spit. Guy ended up with a mass that eroded into his lingual artery (after the fact as per ir). Ent says I can’t believe you could intubate the dude. Miller got the mass out of the way. Yes this is a crazy random story but it happened to me. I tried a number of adjuncts with no luck.

 

[EctopicFetus]

I did my resident research on airways. Played with a bunch of toys. I’ll play devils advocate as someone who is 10+ years out of training. Mac is way better but it is worth learning Miller. Saved me once. But still saved me. I am a huge proponent of vdl. That’s my go to. It’s like a cheat code in a video game. Airways shouldn’t be a 5/10 hard (normal dl) when it could be a 1/10 with vdl. I think learning to place central lines blindly is a worthwhile endeavor as there are some places without us. I learned it this way but use us most of the time. How little residents understand the anatomy and landmarks is sad since they fully rely on us.
my single case where Miller saved me. Guy who doesn’t speak English comes to my solo coverage Ed around midnight. Clear upper airway issue struggling to breath, starts pouring blood out of his mouth. nurse Tells me he has been in our system. A quick review is that this guy has some cancer in his mouth,seen by ent. Long story short I struggle to intubate the guy, video doesn’t help as I suction a canister full of blood and spit. Guy ended up with a mass that eroded into his lingual artery (after the fact as per ir). Ent says I can’t believe you could intubate the dude. Miller got the mass out of the way. Yes this is a crazy random story but it happened to me. I tried a number of adjuncts with no luck.

Oh and I agree on the CRNa flex. Fwiw at my old level one trauma center most of the anesthesia docs used Miller to tube the traumas. In residency we handled airways. I found their technique odd but they were good. Crnas are but another cancer in medicine. Hubris, lack of understanding and overconfidence is a requirement of that field. Move along young doc and don’t let them piss in your cheerios.

 

[turkeyjerky]

I don’t know… I feel like why do something like mac/Miller, or a central line blind… when there are other literature proven methods that increase success and less complications?! I get old habits die hard and if it works for you awesome… but we can agree that it’s no longer standard of care 🙂. Granted if WW3 breaks out and there are power outages everywhere not allowing us to us U/S or VL, but I feel like we will have bigger issues if that’s the case lol.

I don't think the literature base for VL>DL is nearly as strong as you guys make it seem...

Regarding Mac vs Miller, I think you're probably better off mastering one before dabbling in the other. I wanted to be a Miller guy back when I started, but I never found the view as good or the mechanics as intuitive as a Mac. I doubt there are that many cases that are amenable to one or the other with proper use of bimanual laryngcoscopy, and other adjunctive techniques.

 

[HoosierdaddyO]

I mean at every NAEMSP or SOMA or ACEP conference… new literature is showing a resounding first pass success rate with VL compared to that with DL!! I mean I ain’t going to judge someone who feels more comfortable with VL. But that’s like a surgeon who would rather cut someone open with a scalpel when they can and should do a robotic assisted laparoscopy 🤷🏼‍♂️!!! Just because ya can doesn’t mean it’s standard of care?!

 

[EctopicFetus]

I don't think the literature base for VL>DL is nearly as strong as you guys make it seem...

Regarding Mac vs Miller, I think you're probably better off mastering one before dabbling in the other. I wanted to be a Miller guy back when I started, but I never found the view as good or the mechanics as intuitive as a Mac. I doubt there are that many cases that are amenable to one or the other with proper use of bimanual laryngcoscopy, and other adjunctive techniques.

+7% first pass success with VL.

 

[WildEMDoc]

Something that I'm not sure the NEAR database has data on is time to tube passage? Also distinction of hyperangulated VL vs VDL (CMAC etc) in any of the data reviews?

In my mind no matter how skilled you are with a hyperangulated blade, it is substantially faster to pass the tube with a DL blade if you are a skilled operator. That time to tube passage also will impact your first pass rate if you need to come out and bag.

There is no doubt in my mind that curved/mac video laryngoscopy is superior as you now have both a video and true direct modality. The issue is almost no places I've ever worked have a CMAC or something similar, the choices are either DL or hyperangulated. In those situations, DL will always result in faster tube passage if you know what you're doing with either a mac or miller IMO.

 

[coffeebythelake]

Just do whatever you have most experience with and comfortable with. If things are getting difficult I'd rather use a glidescope backup than muck around for the Miller.

 

[PTPoeny]

There is no doubt in my mind that curved/mac video laryngoscopy is superior as you now have both a video and true direct modality. The issue is almost no places I've ever worked have a CMAC or something similar, the choices are either DL or hyperangulated.

This is interesting to hear. What system do you have? Even Glidescope makes Mac and Miller blades. Maybe your hospital just doesn't buy them? Do you have any pediatric VL capability?

 

[Lexdiamondz]

I don’t know… I feel like why do something like mac/Miller, or a central line blind… when there are other literature proven methods that increase success and less complications?! I get old habits die hard and if it works for you awesome… but we can agree that it’s no longer standard of care 🙂. Granted if WW3 breaks out and there are power outages everywhere not allowing us to us U/S or VL, but I feel like we will have bigger issues if that’s the case lol.

Believe it or not, even in 2022 not every shop has appropriately stocked equipment cabinets and so even if you have a glidescope or CMAC always available, you may not always have the appropriate stylets, blade sizes or the screen may just up and die on you.

Couple shifts ago I needed to tube a guy and didn't have the apppropriate glidescope size - used a Mac 4 and it was fine. A few months ago I needed to do a CVL and couldn't find a sterile probe cover for an US - just did a fem with landmarks and it was fine.


The backup to something digital is usually something analog - it's valuable to still know how to do things the old fashioned way

 

[WildEMDoc]

This is interesting to hear. What system do you have? Even Glidescope makes Mac and Miller blades. Maybe your hospital just doesn't buy them? Do you have any pediatric VL capability?

The glidescope Mac blades my residency bought a different glide during my third year (previously had unreliable old glidescope model and DL only), but those are definitely not like a real Mac blade like a CMAC. There is something still off with them I think, and I think its that there is still a weird angle on it so if you try to DL with it it is more difficult than a normal DL. Where I work now all have the old glidescope models that are not compatible with those newer blades but like I said I think they are junk anyway. The site I teach at has a CMAC and it is quite nice and definitely feels like the real DL blade but thats the only place I have it.

Out of the places I've worked since then, one of the places has a glidescope 2 size, but other than that no. DL in kids is all I've ever done though so I don't think I'd reach for a VL outside of if I was at the site I teach at that has a CMAC.

 

[Tenk]

You can use a Mac like a Miller, but you can’t use a Miller like a mac. Miller is inferior. I’ve never used one in like 8 years and don’t plan to ever again.

 

[Arcan57]

Sometimes a Miller will fit into a mouth that you can't fit the equivalent size Mac. It's a rare problem, but it does exist.

 

[BigRedBeta]

Peds intensivist here so different perspective.

Always worth having more tools in your belt in my opinion. I think there's two main considerations in favor of learning a Miller. One is as a learner, the other more pediatrics focused.

As a trainee: If 150 airways is typical for an ED resident over the course of 3-4 years, then there's plenty of opportunity to get comfortable with a number of options. There's absolutely a law of diminishing returns in terms of learning on only one style of blade, so why not use this time in training to maximize your skill set? Never know where you're going to end up in your career and hospital systems like to get cute and do things like only stock 1 type of equipment.


In regards to pediatrics: the extra length of a Miller in my opinion is useful, and gives more flexibility in the midst of the procedure. This is particularly true in infants, as the distance to the chords is less predictable from patient to patient and harder to reliably assess with standard metrics used in adults. It's really hard to get a good view if your blade is too short. Additionally, as @Arcan57 said, there are some mouths that won't fit a Mac very well - this is definitely something more likely to happen in the peds population.

As for my practice...basically have reached the point where I can intubate with whatever is handed to me, so the question becomes irrelevant. If I get in and the view unexpected, I can then change to an option that solves the problem I'm having.

 

[Simba1711]

Anesthesiologist here. Used to be proficient at both in residency but mainly use the Mac blade now. Mac blade is useful for double lumen tubes and At my hospital I only treat adult patients. The Miller blade is useful when they have small mouth opening or floppy epiglottis. In my case , if I’m having trouble getting the ett in I’m grabbing the videolaryngscope.

I think it would be beneficial to learn both types of blades. A few of my favorite anesthesiologists switch between Mac and Miller every other intubation to keep their skills up.

 

[Beeftenderloin]

Don’t necessarily need Mac AND Miller skills. Definitely need DL and VL skills though. If you can find someone to teach you how to use a fiberoptic well enough where you’ll actually use it in practice, you’ll be a rare bird as an EM doc.

And all you jokers talking about intubating “everyone” via DL and a bougie are kidding yourselves. A grade IV view with a Mac or Miller blade is absolutely a real thing, and if you haven’t seen it, you haven’t done enough airways. Good luck passing a bougie when all you see is tongue and soft palate, or on someone with half their mandible missing and radiation changes so whatever’s left looks like it’s carved out of a block of wood. Angioedema, deep space neck infections, compressive airway masses, fractured or fused cervical spines, the list goes on. There are certain situations that absolutely call for more than just DL and a bougie. To say otherwise is peak Dunning-Krueger when it comes to airway management.

 

[GassYous]

Don’t necessarily need Mac AND Miller skills. Definitely need DL and VL skills though. If you can find someone to teach you how to use a fiberoptic well enough where you’ll actually use it in practice, you’ll be a rare bird as an EM doc.

And all you jokers talking about intubating “everyone” via DL and a bougie are kidding yourselves. A grade IV view with a Mac or Miller blade is absolutely a real thing, and if you haven’t seen it, you haven’t done enough airways. Good luck passing a bougie when all you see is tongue and soft palate, or on someone with half their mandible missing and radiation changes so whatever’s left looks like it’s carved out of a block of wood. Angioedema, deep space neck infections, compressive airway masses, fractured or fused cervical spines, the list goes on. There are certain situations that absolutely call for more than just DL and a bougie. To say otherwise is peak Dunning-Krueger when it comes to airway management.

There's nothing that scares me like angioedema, infection or radiation. Super easy to lose an airway. One time I did an awake fiberoptic for a ludwigs, put the scope like it was nothing and thought I was the man. Then when I hooked up the tube, no end tidal. Thought I saw the tube in the airway and had already given prop and roc. The abscess popped so there's blood and pus everywhere and can't get a view. As I start being unable to bag, ENT bailed me out with a trach. Scary.

 

[Arch Guillotti]

There's nothing that scares me like angioedema, infection or radiation. Super easy to lose an airway. One time I did an awake fiberoptic for a ludwigs, put the scope like it was nothing and thought I was the man. Then when I hooked up the tube, no end tidal. Thought I saw the tube in the airway and had already given prop and roc. The abscess popped so there's blood and pus everywhere and can't get a view. As I start being unable to bag, ENT bailed me out with a trach. Scary.

I know someone that happened to also. Pushed drugs but tube was dislodged or whatever. I insist on etco2 becore sedation after afoi.