Decent view of the cords, trouble passing the tube?

[MedicineZ0Z]

Question for the airway experts. I'm still quite inexperienced but here's a persisting problem I'm having.

1. I use the Mac, sweep the tube, advance a bit while lifting and lift a little more as needed.
2. Usually adjust the head (extend).
3. Someone gives me cricoid almost every time.

So at this point, I usually have a decent but not amazing view. The tube is handed to me and it's been with and without the stylette. I try and keep my eye on the cords and take it and advance it. Also tried coming in from the right side of the mouth.
Eventually! I lose a good amount of my view prior to fighting the cords with my tube.

Is there any great approach to remedy this?

Thanks

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[deleted171991]

Your patients are not in sniffing position (ED intubations?) and/or you don't open the mouth enough (i.e. subluxate the jaw) before introducing the blade.

 

[deleted875186]

With the MAC blade, I rarely need to extend the head, usually just lift the blade and head moves natural in position. I also think you may not be positioning well enough. Line the tragus with the sternal notch, get some solid blankets under the head, and a roll under the shoulders if needed.

 

[MedicineZ0Z]

How about with passing the tube?

 

[deleted171991]

How about with passing the tube?

If you have a good view, passing the tube is a piece of cake (unless you lack hand-eye coordination, i.e you'd fail the finger-to-nose exercise).

If you don't have a good view, it takes some mastery to pass the tube. It's not that easy for a beginner.

It should look like this:

... like the one on the left (and not the three on the right):

If you get the second from the left, it may be more difficult to pass the tube. If it gets caught up in the cords, try to rotate it counterclockwise.

 

[hununuh]

I've only done a few months of anesthesia this year, and I used to have similar problem too. When i can't pass the tube through an open cord, i try twisting the tube in (assuming that tube isn't too big and it's the size issue). Another way would be to push the tube in as the stylet comes out. This provides a nice and steady push into the cords. Also, play with the bend of the stylet to find what works best for you.

 

[MedicineZ0Z]

I've only done a few months of anesthesia this year, and I used to have similar problem too. When i can't pass the tube through an open cord, i try twisting the tube in (assuming that tube isn't too big and it's the size issue). Another way would be to push the tube in as the stylet comes out. This provides a nice and steady push into the cords. Also, play with the bend of the stylet to find what works best for you.

Can you explain twisting? would it work if you came in with the tube at 3 oclock, sliding on the right side of the mouth, then go to 12 oclock before you approach the cords?

If you have a good view, passing the tube is a piece of cake (unless you lack hand-eye coordination, i.e you'd fail the finger-to-nose exercise).

If you don't have a good view, it takes some mastery to pass the tube. It's not that easy for a beginner.

I get a decent view but I seem to lose it by the time the tube is approaching (but not yet blocking view) the cords.

 

[hununuh]

You wiggle the tube left and right like how you would screw something in, except you go back and forth instead of going in 1 direction. This assumes that the tip of your tube is literally sitting on the vocal cord, but just won't pass through the cords. Twisting would give you additional traction/force to slide the tube through the cords.

The way you are describing, it looks like you have trouble placing the tip of the tube in front of the cords. Try having steeper bends maybe? If steeper bend doesn't help, your view may not be adequate, which would improve with bigger mouth opening and better laryngoscopy technique. Your goal should be to achieve grade 1 or 2a views.

 

[deleted171991]

I get a decent view but I seem to lose it by the time the tube is approaching (but not yet blocking view) the cords.

There's your mistake. You have to maintain the view. You may also be leaning too close to the patient (as if nearsighted), hence the tube covers your view. You should try to lean away from the patient, as if farsighted, to gain perspective.

Once the tube has somewhat passed the vocal cords, you should ask your helper to pull the stylet (while sliding the tube down the stylet).

Another reason you may be having problems is that your stylet is not properly set up inside the ETT (either too deep or not deep enough). The stylet should end just above the Murphy's eye, and the tube should be curved like a letter J that wouldn't hold water. When introducing the tube, come almost horizontally from the right.

Don't feel bad. It takes a CA-1 resident about 6-9 months before s/he becomes proficient at intubating most (not all) patients. If you are a CA-1, you need to ask a good teacher to observe you and tell you what you're doing wrong ASAP. You may have already been labelled as a problem. Unfortunately, most attendings suck at figuring out what's wrong with one's intubation technique (at least they did for me). 😉

 

[MedicineZ0Z]

You wiggle the tube left and right like how you would screw something in, except you go back and forth instead of going in 1 direction. This assumes that the tip of your tube is literally sitting on the vocal cord, but just won't pass through the cords. Twisting would give you additional traction/force to slide the tube through the cords.

The way you are describing, it looks like you have trouble placing the tip of the tube in front of the cords. Try having steeper bends maybe? If steeper bend doesn't help, your view may not be adequate, which would improve with bigger mouth opening and better laryngoscopy technique. Your goal should be to achieve grade 1 or 2a views.

Yeah it's definitely trouble placing it in front of the cords and also losing my view (left hand slipping I think) in the process.

There's your mistake. You have to maintain the view. You may also be leaning too close to the patient (as if nearsighted), hence the tube covers your view. You should try to lean away from the patient, as if farsighted, to gain perspective.

Once the tube has somewhat passed the vocal cords, you should ask your helper to pull the stylet (while sliding the tube down the stylet).

Another reason you may be having problems is that your stylet is not properly set up inside the ETT (either too deep or not deep enough). The stylet should end just above the Murphy's eye, and the tube should be curved like a letter J that wouldn't hold water. When introducing the tube, come almost horizontally from the right.

Don't feel bad. It takes a CA-1 resident about 6-9 months before s/he becomes proficient at intubating most (not all) patients. If you are a CA-1, you need to ask a good teacher to observe you and tell you what you're doing wrong ASAP. You may have already been labelled as a problem. Unfortunately, most attendings suck at figuring out what's wrong with one's intubation technique (at least they did for me). 😉

I'm actually an MS4! I think the leaning too close part is definitely something I'm doing.

How many intubations does it take most people to get basic skills down?

 

[Twiggidy]

How about with passing the tube?

Lube

 

[Arch Guillotti]

Yeah it's definitely trouble placing it in front of the cords and also losing my view (left hand slipping I think) in the process.

I'm actually an MS4! I think the leaning too close part is definitely something I'm doing.

How many intubations does it take most people to get basic skills down?

40.

 

[nimbus]

You should enter the mouth at the right corner of the lips and hold the tube so it’s perpendicular to the midsaggital plane of the patient so that the proximal end of the tube is pointing to the right. Many beginners enter through the middle of the mouth and hold the tube parallel to or in the midsaggital plane with the proximal end pointing to the ceiling. That makes it impossible not to obscure your view with the tube and your own hand. Keep the tube and your hand to the right of the sight line.

And as others have said above, stand up straight. It gives you more perspective.

 

[deleted697127]

I get a decent view but I seem to lose it by the time the tube is approaching (but not yet blocking view) the cords.

Form ETT prior to induction so you are not messing with it after finding your view. Consider discussing BEFORE induction with attending for the day how they typically form stylette to limit the chance they change the bend to something strange last second as this may throw you off.

Tilt the head back with your right hand, scissor (as wide or wider than the patient opened when checking airway exam!), slide blade in and tongue sweep, take right hand and apply pressure over anterior neck to improve view if needed, ask someone to hold where you positioned the neck with your hand. Do not look away while grabbing tube!

If you do lose your view, get the view back. Do not proceed blindly. Announce what view you have. “Grade 1 view.” “Cords are open.” If you do not tell us what you’re seeing and ask for a bougie the case after you tubed the esophagus, people may judge you. Be realistic. If you know you can ventilate, most people would prefer you ask for help improving the view than proceed haphazardly.

Take your time. If you can mask ventilate you can go as slow as you need to in order to not jack up someone’s lips.

If you do tube the esophagus, ask for feedback. Be prepared for an honest response. Feedback helps you get better. We’ve all been there.

 

[MedicineZ0Z]

You should enter the mouth at the right corner of the lips and hold the tube so it’s perpendicular to the midsaggital plane of the patient so that the proximal end of the tube is pointing to the right. Many beginners enter through the middle of the mouth and hold the tube parallel to or in the midsaggital plane with the proximal end pointing to the ceiling. That makes it impossible not to obscure your view with the tube and your own hand. Keep the tube and your hand to the right of the sight line.

And as others have said above, stand up straight. It gives you more perspective.

Form ETT prior to induction so you are not messing with it after finding your view. Consider discussing BEFORE induction with attending for the day how they typically form stylette to limit the chance they change the bend to something strange last second as this may throw you off.

Tilt the head back with your right hand, scissor (as wide or wider than the patient opened when checking airway exam!), slide blade in and tongue sweep, take right hand and apply pressure over anterior neck to improve view if needed, ask someone to hold where you positioned the neck with your hand. Do not look away while grabbing tube!

If you do lose your view, get the view back. Do not proceed blindly. Announce what view you have. “Grade 1 view.” “Cords are open.” If you do not tell us what you’re seeing and ask for a bougie the case after you tubed the esophagus, people may judge you. Be realistic. If you know you can ventilate, most people would prefer you ask for help improving the view than proceed haphazardly.

Take your time. If you can mask ventilate you can go as slow as you need to in order to not jack up someone’s lips.

If you do tube the esophagus, ask for feedback. Be prepared for an honest response. Feedback helps you get better. We’ve all been there.

Very useful, thanks!!

I also think I squeeze the blade too hard and fully tense up.

 

[coffeebythelake]

Holding the laryngoscope requires a fair bit for forearm strength as well. I've seen many new residents and srnas struggle to maintain a good view for 3xactly this reason. Arms start to shake and waver.

 

[norski]

Also a learner intubator (student nurse anesthetist), sub 50 successful intubations on record. Take that for what it's worth, one novice to another.

If my patient is a BMI 35-40 male with a beard, I try to just make things easy for myself. I use my right hand for taking the brunt of the work out of keeping a nice jaw thrust/mask seal, maybe get my attending or CRNA babysitter to bag while I maintain the airway.
So: Right hand for mask seal/jaw thrust, left hand for laryngoscopy. If the patient has a BMI in the normal range, the left hand gets all of the hard work.

Then when it's time to rock after roc has done it's thing, I place my right thumb as far back in the patient's lower jaw and push gently. This accomplishes a couple of things:

1) I get a feel for how well the NMB is working (if TOF's not available), or if the patient can even subluxate the lower jaw, and;
2) The force I have to apply to the vallecula with the tip of the blade to get an optimal view is less than when I did the scissoring technique for opening the jaw (no real measurements done here, but it certainly feels like lesser force is applied). Once I have a view I'm happy with, I keep the pressure of the blade where it still is,withdraw my thumb, get my tube, then guide through the cords.
3) If my blade touches my thumb while still in the oral cavity, that means I have to move my blade more medially before advancing, if not, chances are good that all I'll ever see is tonsils. Bonus: the tongue is pulled along with the blade, making not only the view more optimal, but the intubation conditions, regardless of view gets a touch better, as I get more room in the right side of the oral cavity.

Sounds pretty banal, and this technique requires, like any other successful intubation, proper positioning, but it works. At least for me. Most trouble I've ever had actually intubating, while having a grade 1 view, was due to having a chunk of tongue on my right, blocking the tube's passage towards the cords.

Hope that helps for someone. I'm very much open to ridicule due to my thumb technique. Heh.

 

[BobLoblaw78]

Question for the airway experts. I'm still quite inexperienced but here's a persisting problem I'm having.

1. I use the Mac, sweep the tube, advance a bit while lifting and lift a little more as needed.
2. Usually adjust the head (extend).
3. Someone gives me cricoid almost every time.

Thanks

Never sweep the tube!

Sweep the leg! You gotta problem with that?

 

[coffeebythelake]

Cricoid pressure does not improve your CL view, in fact it may worsen it.

The BURP maneuver and external laryngeal manipulation maneuvers are appropriately used to improve the CL view. It involves pressure and manipulation of the thyroid cartilage, not the cricoid.

 

[Arch Guillotti]

Cricoid pressure does not improve your CL view, in fact it may worsen it.

The BURP maneuver and external laryngeal manipulation maneuvers are appropriately used to improve the CL view. It involves pressure and manipulation of the thyroid cartilage, not the cricoid.

Of course but the two terms are used interchangeably😕

 

[deleted59964]

There's your mistake. You have to maintain the view. You may also be leaning too close to the patient (as if nearsighted), hence the tube covers your view. You should try to lean away from the patient, as if farsighted, to gain perspective.

Do this, and your success rate will improve

 

[Twiggidy]

It really is one of the better pieces of advice. Stand up straight and with confidence. I got so sick of seeing residents hunch over a patient as if getting closer to the mouth will improve the view. No. It will only hurt your back and get some of the patients breath (or whatever else may come out of the mouth) in your face.

Stand up
Sweep the tongue with the blade to the left
Aim the handle towards where the wall and ceiling meet on the opposite side of the room so you're not leaning on teeth
Put the tube through the cords

And as someone else said......Take you time and GO SLOW. There's no rush. One day when you're an attending you'll essentially be getting "paid by the hour" if you're productivity based so what's the hurry?

 

[MedicineZ0Z]

It really is one of the better pieces of advice. Stand up straight and with confidence. I got so sick of seeing residents hunch over a patient as if getting closer to the mouth will improve the view. No. It will only hurt your back and get some of the patients breath (or whatever else may come out of the mouth) in your face.

Stand up
Sweep the tongue with the blade to the left
Aim the handle towards where the wall and ceiling meet on the opposite side of the room so you're not leaning on teeth
Put the tube through the cords

And as someone else said......Take you time and GO SLOW. There's no rush. One day when you're an attending you'll essentially be getting "paid by the hour" if you're productivity based so what's the hurry?

Thanks. How high do you raise the table exactly? I find it's a tiny bit low for me cause I'm slightly taller than the residents and they seem to adjust to their preferable height.

 

[deleted162650]

Thanks. How high do you raise the table exactly? I find it's a tiny bit low for me cause I'm slightly taller than the residents and they seem to adjust to their preferable height.

The classic rule is pt’s forehead even with your xiphoid, but just put it where it’s comfortable dude.

 

[Twiggidy]

Thanks. How high do you raise the table exactly? I find it's a tiny bit low for me cause I'm slightly taller than the residents and they seem to adjust to their preferable height.

For how annoying it is to hear "table up" "table down" during an surgery, they do it for a reason. Unless you're Shaq (and if you are, what up Diesel!) bring the table up to your chest

 

[deleted171991]

.

It really is one of the better pieces of advice. Stand up straight and with confidence. I got so sick of seeing residents hunch over a patient as if getting closer to the mouth will improve the view. No. It will only hurt your back and get some of the patients breath (or whatever else may come out of the mouth) in your face.

Stand up
Sweep the tongue with the blade to the left
Aim the handle towards where the wall and ceiling meet on the opposite side of the room so you're not leaning on teeth
Put the tube through the cords

And as someone else said......Take you time and GO SLOW. There's no rush. One day when you're an attending you'll essentially be getting "paid by the hour" if you're productivity based so what's the hurry?

People don't stand up straight because they put the bed too low. The bed should be at the level of the intubator's xiphoid.

 

[Impromptu]

Yeah it's definitely trouble placing it in front of the cords and also losing my view (left hand slipping I think) in the process.

I'm actually an MS4! I think the leaning too close part is definitely something I'm doing.

How many intubations does it take most people to get basic skills down?

The first 10,000 are hard.

I had an attending that had been working since 1978. He was the one everyone went to for help when they couldn't get the IVs and arterial lines in the neonates for cardiac surgery. He was an excellent teacher. When asked how he was so good at what he did, he would often reply, "the first 10,000 are hard". For some things, this might be a bit of hyperbole, but I would hope that I will continue to get better over the decade or 2 it takes to reach 10,000 of any procedure.

 

[dhb]

just put it where it’s comfortable

Didn't expect anything less from you!

Table to the xiphoid? That takes way to long...

 

[getdown]

Try not using a stylet and gently use a rocking motion of your wrist to put the tube in.

 

[deleted59964]

Never sweep the tube!

Sweep the leg! You gotta problem with that?

 

[MedicineZ0Z]

What's the best way to handle a large epiglottis with a Mac?
Attending pushes trachea to the right, I still cant get a good view.. I lift and still nothing. Am I not in deep enough if i still see flapping down?

 

[nimbus]

What's the best way to handle a large epiglottis with a Mac?
Attending pushes trachea to the right, I still cant get a good view.. I lift and still nothing. Am I not in deep enough if i still see flapping down?

Yes.


Push the tip of the blade deeper into the vallecula to engage the hyoepiglottic ligament, then lift. If you are not deep enough, you will be lifting the soft elastic tissue at the base of the tongue which won’t move the epiglottis as effectively. You need to lift the firm ligament which is attached to the base of the epiglottis.

 

[MedicineZ0Z]

Great advice in this thread. I guess every tube seems to be either... go in and viola amazing grade 1 view. Or... go in and see epiglottis and some crappy view or nothing + attending giving me cricoid etc., no time to fine tune as a student because if you can't see it fairly quickly the resident takes over.
Really think a sim lab would be very beneficial to getting the fine tune movements now to optimize the view without the stress of a obese patient desatting.

 

[deleted697127]

This partially depends on what your “fine tune movements” are. It’s fairly common to discuss intubating with someone and then have them immediately crank back on the teeth despite repeated conversations. If it looks like you may be hurting someone’s throat with your adjustments, they’re more likely to take over. Again, no offense, most people probably unconsciously did this when they were learning for whatever reason.

Again, go slow. As you are ventilating, in an undemanding way say “alright easy mask ventilation, can you watch my technique as I’m going in to make sure I’m off the teeth. we know we can ventilate, can you help me adjust to get the view myself if it’s not grade 1 right off the bat.” Understand that there is little discussion or training for residents on when or if to take over. Expectations can be challenging. Discussing may help.

In general, people are less likely to take over if you are prepared, organized, and communicate well. If you go to do an epidural, struggle with sterility, your tray is a mess, and you don’t appear to know what comes in the kit, it suggests you may not know what you’re doing.

Don’t be afraid to ask for feedback, I assure you the attending and resident were watching.

 

[MedicineZ0Z]

BTW, any thoughts on airway courses/practice in sim labs/cadavers etc? Particularly with clinical grade cadavers. Seems like it's very ideal for perfecting the fine tune movements and getting a ton of reps with different tools.

 

[MirrorTodd]

What is a clinical grade cadaver?

 

[deleted162650]

What is a clinical grade cadaver?

It’s a step above hamburger grade, but not quite sushi grade.

 

[nimbus]

What is a clinical grade cadaver?

It’s a step above hamburger grade, but not quite sushi grade.

In terms of clinical grade beef cadavers...

hamburger is a pass
prime ribeye is high pass
A5 wagyu is honors

 

[MaximusD]

Question for the airway experts. I'm still quite inexperienced but here's a persisting problem I'm having.

1. I use the Mac, sweep the tube, advance a bit while lifting and lift a little more as needed.
2. Usually adjust the head (extend).
3. Someone gives me cricoid almost every time.

So at this point, I usually have a decent but not amazing view. The tube is handed to me and it's been with and without the stylette. I try and keep my eye on the cords and take it and advance it. Also tried coming in from the right side of the mouth.
Eventually! I lose a good amount of my view prior to fighting the cords with my tube.

Is there any great approach to remedy this?

Thanks

If you have this view (typically a grade 2 view), don't **** around with an unstyletted tube unless it has been pre-coiled for a while.

Take a moment, and ask a second operator to stylet the tube with the traditional bend.

If you attempt to pass the styletted tube and are unsuccessful yet the airway is untraumatized -- while maintaining view of the cords -- exaggerate the anterior bend of the styletted tube and attempt to pass.

If it does not pass and only a few moments have passed, you may consider a bougie on current or next attempt.

ORRRRR... call for a glide before your bloody the airway.

Good luck, and good question.

Also... this may indicate you've done a poor job of optimizing patient position. It is very important to align the view by putting the patient in the "sniff" position. Simple repositioning between attempts can change your life vastly.... just be wary of contraindications of extending the neck harshly (RA, known cervical spine disease with radiculopathy, downs, etc).

 

[MedicineZ0Z]

If you have this view (typically a grade 2 view), don't **** around with an unstyletted tube unless it has been pre-coiled for a while.

Take a moment, and ask a second operator to stylet the tube with the traditional bend.

If you attempt to pass the styletted tube and are unsuccessful yet the airway is untraumatized -- while maintaining view of the cords -- exaggerate the anterior bend of the styletted tube and attempt to pass.

If it does not pass and only a few moments have passed, you may consider a bougie on current or next attempt.

ORRRRR... call for a glide before your bloody the airway.

Good luck, and good question.

Also... this may indicate you've done a poor job of optimizing patient position. It is very important to align the view by putting the patient in the "sniff" position. Simple repositioning between attempts can change your life vastly.... just be wary of contraindications of extending the neck harshly (RA, known cervical spine disease with radiculopathy, downs, etc).

Thank for the tips! I honestly have very little confidence with a grade 2 view cause I always seem to lose my view at the end and then can just feel it going esophagus. In an emergent setting, should I just give up on DL with gr 2 view and put in the glide asap instead?
Also for positioning, I find the hardest part is knowing what to grab since different body sizes +/- anterior airway makes it hard to know if you need 1 pillow or if you should get a bunch of blankets etc.

 

[deleted171991]

We have a saying: there is a reason anesthesia residency is 3 years.

 

[coffeebythelake]

We have a saying: there is a reason anesthesia residency is 3 years.

4 years

 

[deleted171991]

4 years

If you count the internship.

 

[norski]

You could just DL and bougie the MFer(the C/L 2). If done right, it's a lot more gentle than fighting the cords and soft tissue with a stylet tube. As long as you actually see the cords, a bougie is easier to pass than a tube, and you don't need to ram it into the left mainstem causing trauma to the bronchus (as antagonists of the bougie seem afraid of).

Thank for the tips! I honestly have very little confidence with a grade 2 view cause I always seem to lose my view at the end and then can just feel it going esophagus. In an emergent setting, should I just give up on DL with gr 2 view and put in the glide asap instead?
Also for positioning, I find the hardest part is knowing what to grab since different body sizes +/- anterior airway makes it hard to know if you need 1 pillow or if you should get a bunch of blankets etc.

 

[coffeebythelake]

You could just DL and bougie the MFer(the C/L 2). If done right, it's a lot more gentle than fighting the cords and soft tissue with a stylet tube. As long as you actually see the cords, a bougie is easier to pass than a tube, and you don't need to ram it into the left mainstem causing trauma to the bronchus (as antagonists of the bougie seem afraid of).

I'm a fan of the bougie, but this seems like a lot of trouble for a CL2 view

 

[norski]

Agreed, and usually a precoiled tube will do the trick(sans stylet) ,but if there's routinely issues for the poster intubating CL2s, a bougie is a nice crutch.

Of course, a CL2 in an inexperienced (like myself) laryngoscopist's hands often melts into a CL1 in more experienced hands.

Also, a bougie shouldn't be more of a fuzz than using a stylet. Do the Kiwi grip!

I'm a fan of the bougie, but this seems like a lot of trouble for a CL2 view

 

[Drwine]

Learn to properly use a Miller blade. Just remember it is a "snow shovel" and not a "crowbar". 😉

 

[norski]

We don't have any millers except sz 0 and 1. Are they commonly used in the US?

Learn to properly use a Miller blade. Just remember it is a "snow shovel" and not a "crowbar". 😉

 

[Drwine]

We don't have any millers except sz 0 and 1. Are they commonly used in the US?

We have very good availability of Miller 2 & 3 blades.

 

[norski]

I realize I'm not in a position to ask questions here, but I'm wondering if it's easy for the newbie to "scrape" the cords with the tip using a miller when lifting the epiglottis directly?