Chin-tuck intubation???

[AJM]

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So this ENT guy was giving us a lecture today on vocal cord surgeries, and in the middle of his talk he took about 2 minutes to tell us about this different intubation technique he uses. (It was just long enough for us to go "what the f***?", but not long enough for us to figure out how the heck this could possibly work).

He said that he has many patients who you can't get good visualization with DL in the sniff position, so what he does instead is to lift the patient's head off the table and tuck their chin to their chest, then stand at the side of the pt and do a DL from there -- apparently you can often get better views in that position. 😕 😕 😕 He even showed us a video of him doing it -- he made it look quite easy.

My question is: WTF? Have you guys ever heard of this technique or done it yourselves? If you have, how the heck does it work? I just can't picture how it could be easier than a "normal" intubation.

 

[Skrubz]

So this ENT guy was giving us a lecture today on vocal cord surgeries, and in the middle of his talk he took about 2 minutes to tell us about this different intubation technique he uses. (It was just long enough for us to go "what the f***?", but not long enough for us to figure out how the heck this could possibly work).

He said that he has many patients who you can't get good visualization with DL in the sniff position, so what he does instead is to lift the patient's head off the table and tuck their chin to their chest, then stand at the side of the pt and do a DL from there -- apparently you can often get better views in that position. 😕 😕 😕 He even showed us a video of him doing it -- he made it look quite easy.

My question is: WTF? Have you guys ever heard of this technique or done it yourselves? If you have, how the heck does it work? I just can't picture how it could be easier than a "normal" intubation.

*scratching head* maybe by tucking the chin in, he's physically forcing the larynx and vocal cords into a more posterior position? i've had some of my pedi attendings poo-poo the idea of using a shoulder roll in certain kids (particularly the really small neonates) because they believe that it just makes the anterior airway even more anterior.

 

[jetproppilot]

So this ENT guy was giving us a lecture today on vocal cord surgeries, and in the middle of his talk he took about 2 minutes to tell us about this different intubation technique he uses. (It was just long enough for us to go "what the f***?", but not long enough for us to figure out how the heck this could possibly work).

He said that he has many patients who you can't get good visualization with DL in the sniff position, so what he does instead is to lift the patient's head off the table and tuck their chin to their chest, then stand at the side of the pt and do a DL from there -- apparently you can often get better views in that position. 😕 😕 😕 He even showed us a video of him doing it -- he made it look quite easy.

My question is: WTF? Have you guys ever heard of this technique or done it yourselves? If you have, how the heck does it work? I just can't picture how it could be easier than a "normal" intubation.

Sounds like the dude knows his s hit.

I did my residency under a british chairman who used a Mac 3, no-matter-what.

Dr. Grogono (chair dude) could intubate an ant's fetus.

If he was in house and a difficult intubation came about,

Dr Grogono was called.

And I never saw the dude miss.

And I was in on some VERY difficult airways with him.

What did he do?? (keep in mind he always used a Mac 3)

1) Drop OR table to max-low-position.

2) Raise pts head as much as possible with pillows (hence aligning the axes)

3) So I'd be standing there. Seriously. Pts chin nearly touching their chest from the positioning. I'm like, ... WTF? ...how are you, Dr. Grog, gonna even-get the blade in????

4) Dr Grog always got the blade in.

And he always got the tube in.

Seriously.

Never saw him miss.

 

[jetproppilot]

Sounds like the dude knows his s hit.

I did my residency under a british chairman who used a Mac 3, no-matter-what.

Dr. Grogono (chair dude) could intubate an ant's fetus.

If he was in house and a difficult intubation came about,

Dr Grogono was called.

And I never saw the dude miss.

And I was in on some VERY difficult airways with him.

What did he do?? (keep in mind he always used a Mac 3)

1) Drop OR table to max-low-position.

2) Raise pts head as much as possible with pillows (hence aligning the axes)

3) So I'd be standing there. Seriously. Pts chin nearly touching their chest from the positioning. I'm like, ... WTF? ...how are you, Dr. Grog, gonna even-get the blade in????

4) Dr Grog always got the blade in.

And he always got the tube in.

Seriously.

Never saw him miss.

JET'S SYNOPSIS:

if you're using a Mac, the higher the pts head on a pillow, the better.

if you're using a Miller, remove the pillow. Best case scenerio if you are having problems is a shoulder roll with no pillow.

 

[AJM]

Sounds like the dude knows his s hit.

I did my residency under a british chairman who used a Mac 3, no-matter-what.

Dr. Grogono (chair dude) could intubate an ant's fetus.

If he was in house and a difficult intubation came about,

Dr Grogono was called.

And I never saw the dude miss.

And I was in on some VERY difficult airways with him.

What did he do?? (keep in mind he always used a Mac 3)

1) Drop OR table to max-low-position.

2) Raise pts head as much as possible with pillows (hence aligning the axes)

3) So I'd be standing there. Seriously. Pts chin nearly touching their chest from the positioning. I'm like, ... WTF? ...how are you, Dr. Grog, gonna even-get the blade in????

4) Dr Grog always got the blade in.

And he always got the tube in.

Seriously.

Never saw him miss.

That's pretty sweet. I thought this guy had a lapse of crazy-talk, but it sounds like this has been done before. And yes, he is overall a pretty bad-ass surgeon.

He didn't tell us what kind of blade he used, but in the video it looked like a Miller variant......

 

[militarymd]

I work with a CRNA who does this every time...drives me bonkers watching her, because it is a difficult mask position.

 

[bullard]

I think this is the position Benumof advocates using for obese patients -- better than usual approach for aligning your axes. Saw it used a few times on my anesthesia rotations. Let me see if I can find an article.

There was a company at the ASA convention in Atlanta selling a disposable antibacterial pillow to use to get the position instead of towels.

 

[bullard]

For what it's worth:

http://www.mercurymed.com/pdf/collins.pdf

 

[IceDoc]

So this ENT guy was giving us a lecture today on vocal cord surgeries, and in the middle of his talk he took about 2 minutes to tell us about this different intubation technique he uses. (It was just long enough for us to go "what the f***?", but not long enough for us to figure out how the heck this could possibly work).

He said that he has many patients who you can't get good visualization with DL in the sniff position, so what he does instead is to lift the patient's head off the table and tuck their chin to their chest, then stand at the side of the pt and do a DL from there -- apparently you can often get better views in that position. 😕 😕 😕 He even showed us a video of him doing it -- he made it look quite easy.

My question is: WTF? Have you guys ever heard of this technique or done it yourselves? If you have, how the heck does it work? I just can't picture how it could be easier than a "normal" intubation.

The ENT's will often use their Hollinger scope for difficult airways. Also, they will also approach from the side with this scope; perhaps this guy was even modifying that technique.

 

[camkiss]

I use something like this if I can't see cords while lifting up and out with the laryngoscope handle in the traditional method.
I point the handle towards the feet, thus effectively tucking the chin. Then I pull towards the feet and lift the patient's head slightly off the bed. I can almost always get a better view this way if the traditional method did not work. A peds anesthesiologist showed this to me.

 

[burntcrispy]

The chin-tuck style position works well for nasal intubations. An attending showed me this and she claims that over 90% of the time it will go in without having to use MG forceps. Seemed to work fine when I tried it.

 

[VentdependenT]

speakin of nasotracheal intubations what do you guys use as far preintubation nostril care.

Xylocaine and nasal neosynephrine? Have you ever had systemic htn from nasal neosynephrine?

or cocaine?

do you prestretch the nostril with some nasal airways pre intubation?

Also, is it true that one should place the nasal airway in the nostril which allows the beveled end to be advanced against the septum (cant recall if L or R is beveled)?

 

[rn29306]

speakin of nasotracheal intubations what do you guys use as far preintubation nostril care.

Xylocaine and nasal neosynephrine? Have you ever had systemic htn from nasal neosynephrine?

or cocaine?

do you prestretch the nostril with some nasal airways pre intubation?

Also, is it true that one should place the nasal airway in the nostril which allows the beveled end to be advanced against the septum (cant recall if L or R is beveled)?

Neosynephrine 1ml snort in each nostril in PreOp.
To OR, preox, IV induction. Have 3 nasal airways, soaked in hot water previously with a liberal amount of Lidocaine jelly on it.

Airway # 1, mask. Airway #2, mask. Airway #3, mask.

Nasal ETT taken out of bottle of warm water. I like to use a red rubber catheter over the end of the ETT to prevent nasal gouging with the open tip of the ETT. Pop off RRC after passage through nasal canal complete, slide ETT in.

Have never used cocaine, but would like to try it on soneone one day.
Never seen a systemic reaction of nasal neo, but I'm sure my day is coming soon.