Grade 1 view of the cords but cant intubate?

[ToKingdomCome]

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This has happened a couple of times during residency. I know about slightly removing the stylet and then trying to pass the tube and also rotating the tube clockwise. Sometimes this fails as well. Does anyone have any additional tips to try and pass the tube before jumping to a smaller one?

 

[deleted162650]

This has happened a couple of times during residency. I know about slightly removing the stylet and then trying to pass the tube and also rotating the tube clockwise. Sometimes this fails as well. Does anyone have any additional tips to try and pass the tube before jumping to a smaller one?

Skip the stylet all together. This is happening because you have too acute an angle on the stylet.

 

[nimbus]

Agree stylette is probably the problem. You can learn to feed/advance the tube off the stylette with one hand too.

 

[ToKingdomCome]

Agree stylette is probably the problem. You can learn to feed/advance the tube off the stylette with one hand too.

So you’re saying if I’m intubating with a stylette and it’s not passing just ask the nurse to slowly pull the stylette out and try to pass the tube that way?

I guess I can start trying to intubate without a stylet any things that make this more challenging? What kind of curvature should I have on the tube without stylette?

 

[nimbus]

So you’re saying if I’m intubating with a stylette and it’s not passing just ask the nurse to slowly pull the stylette out and try to pass the tube that way?

I guess I can start trying to intubate without a stylet any things that make this more challenging? What kind of curvature should I have on the tube without stylette?

Yes. You can do it yourself without a nurse. Hold the tube at the proximal end and advance the tube off the stylette while keeping the stylette hooked over your thumb.

I personally like a stylette but I know many others don’t routinely use them.

 

[Choo]

Could also try putting a boogie backwards through the tube after the stylet is out.

 

[deleted875186]

Any time I’ve ever had trouble passing a tube, stylet is removed and it goes in easy.

 

[urge]

I cannot fathom how this scenario (grade 1 view via direct laryngoscopy but cannot intubate) is even possible.

Did people stop playing with sticks as kids?

Even with the Glidescope I still have a hard time understanding how people manage to have so much trouble intubating when they can get a good view. But I see it all the time, and I have no other remedy than accept reality.

 

[deleted162650]

This thread is a great breeding ground for some off color jokes.

 

[IlDestriero]

Reverse load the tube, it will naturally flex downward and into the trachea as you remove the stylette after engaging the tip in the trachea.

 

[MirrorTodd]

I cannot fathom how this scenario (grade 1 view via direct laryngoscopy but cannot intubate) is even possible.

Did people stop playing with sticks as kids?

Even with the Glidescope I still have a hard time understanding how people manage to have so much trouble intubating when they can get a good view. But I see it all the time, and I have no other remedy than accept reality.

Well we can't all be perfect.

 

[urge]

Reverse load the tube,

Don’t follow you.

Do you mean to bend the stylette against the curvature of the tube?

 

[deleted162650]

Don’t follow you.

Insert the end with the circuit adapter on it 😉

 

[urge]

Insert the end with the circuit adapter on it 😉

Reverse load actually means that.

Poor choice of words indeed.

 

[kidthor]

Two thoughts:

-Something about the laryngoscope blade technique is off. If the tongue is not well swept to the left or blade is either on the right or not just a bit left of center, then you'll have too much tongue/tissue in the way of your view / ETT-entry real estate.

-Insertion may be messed up. This can be due to a weirdly styletted ETT. I make mine rather straight - however many make things rather hooked, which makes the whole ETT maneuvering odd. Not styletting the tube is a good suggestion to correct this issue. Note the ENTs have their ETTs almost entirely straight and usually we can all see it go in on their video scopes. Or, it can be that you are inserting at 0 degrees and need to rotate a bit clockwise (0 deg makes your hand and the tube fully block your view). Insert at 30 deg to 60 deg CW when you enter the oropharynx, then twist to 0 deg once you are passing through the cords.

 

[DrOwnage]

Yeah this doesn't happen to me very often, something fundamental is off. You might be intubating with the patient not fully paralyzed and getting a lot of resistance from the cords and surrounding tissue, at least thats when it would happen when the patient isn't deep enough/not paralyzed. I'll notice this if I push Succ and intubate exactly when they start fasciculating. I cant remember the last time I wasn't able to fit a 7.0-7.5 in anyone, even 4'10" little ladies.

 

[Ezekiel2517]

Even in training, I never understood the crazy different shapes/forms ppl would stylet the ETT into. The curve the ETT's come in the packaging is actually the optimal shape imo. There's a reason they come packaged like that. If you stylet it, try to mimic the same curvature it comes in the packaging.

 

[coffeebythelake]

Even in training, I never understood the crazy different shapes/forms ppl would stylet the ETT into. The curve the ETT's come in the packaging is actually the optimal shape imo. There's a reason they come packaged like that. If you stylet it, try to mimic the same curvature it comes in the packaging.

Was taught in training that hockey stick shape is the "proper" way

 

[Ezekiel2517]

Was taught in training that hockey stick shape is the "proper" way

Some of them tried to teach me that too in residency. Luckily, I had a badass OG attending who taught me that was nonsense.

 

[IlDestriero]

Don’t follow you.

Do you mean to bend the stylette against the curvature of the tube?

It called reverse loading because the natural curve of the tube is in the reverse of the usual intubation position. You make your usual stylette bend, but the tube is loaded on reversed 180 degrees. If you can’t advance the tube into the trachea, after you engage the tip in the glottis, when you slowly remove the stylette, the tube will flex downward and assist in making the drop into the trachea.

 

[Shimmy8]

This thread is a great breeding ground for some off color jokes.

- I have the same problem in the summer when it's hot, just need more lube

- try reverse cowgirl, makes the angle a little easier

- ask the nurse to use both hands, often helps position toward the hole better

- natural curve does make it a little tricky sometimes

- prob in the wrong hole

COME ON PEOPLE

 

[Southpaw]

I like my tube straight when entering the trachea. Also long ago I learned putting something through my tube, along with inducing strange angles, made advancement more difficult. In long, I’m a straight tuber all the way.

 

[Iso4ane]

Dumb question, are you using a MIller or a Mac blade? There is some evidence that shows easier views with a Miller but you have a little less space to work with.

 

[26B]

Use a Miller blade and you won't need a stylet.

 

[ToKingdomCome]

I like my tube straight when entering the trachea. Also long ago I learned putting something through my tube, along with inducing strange angles, made advancement more difficult. In long, I’m a straight tuber all the way.

I have never heard of anyone literally having a straight tube, but this makes sense anatomically? I guess going forward I'm going to less hockey stick it and have less of an acute angle and try to just use the tube in the natural curve that comes in the packaging.

 

[vector2]

I go arcuate with much less of a bend than what's in the picture above. Hockey stick is acceptable only if the bend angle is really gentle. Those crazy 60-90 degree hockey stick bends guarantee that the ETT tip will snag on the glottis or anterior trachea and it'll require someone to pull the stylet back to let the angle flatten a bit.

 

[Southpaw]

I have never heard of anyone literally having a straight tube, but this makes sense anatomically? I guess going forward I'm going to less hockey stick it and have less of an acute angle and try to just use the tube in the natural curve that comes in the packaging.

I was more joking than anything to be honest after reading the reverse load stuff. like LMAs I don't think much about ETTs anymore. I used to ask myself lots of questions about insertion technique of LMAs and ETTs, and I've watched others as well. I developed my technique after thousands of attempts, literally, so I feel good about it.

I like the Mac blade because it makes anatomical sense and it gives me plenty of room to place a stylet-less ETT. I pay attention to patient positioning when they move over from the stretcher so that they are where I want/need them when I go to place the ETT/LMA. I've never been a hockey stick stylet-er because the stylet forces you to have help or get used to sliding the ETT off one-handed. the hockey stick shape, or exaggerated bends, is what gets you stuck at the glottic opening. same thing happens with the glidescope. personally I take the ETT out of the packaging, check the cuff, and use as is. doing that I've never gotten stuck as you describe in the OP.

also, being adequately deep and paralyzed helps immensely. giving 40mg or 50mg to above average sized adults and not thinking about your dose, and then trying to intubate 15 seconds later, is really dumb and yet I see people do it all the time. I'm not saying that's what YOU do, it's just on my mind as I type. I use heavier (i.e. appropriate per weight and dose reccs) doses of roc, especially with suggamadex readily available in my system, because I've noticed it helps with intubation.

 

[ButterButter]

I'm sure everyone has said this (but I'm too lazy to read all the posts): lube the tube (you don't intubate the urethra with a dry foley, why would you do it with the trachea?), don't try to pass the whole damn thing with the stylet still in, regardless of your view. When you use VL, you get the tube in but don't advance all the way until the stylet comes out. Same thing with dl. If you have a grade 1 view, you're looking straight into the trachea. A straight line. An ETT with formed stylet is only hurting you (unless of course it's perfectly straight). That being said, you don't know if you're gonna get a grade 1 when you start so a stylet is still probably justified. Get savvy with popping the stylet out with one hand and advancing. Alternatively, put the tip of the tube right at the cords and ask for the stylet to me removed slowly as you advance off and in. And as you already mentioned, if you're truly stuck on rings, twisting will get it through (and if it's lubed, it'll go right in).

 

[abolt18]

Like butter

I'm sure everyone has said this (but I'm too lazy to read all the posts): lube the tube (you don't intubate the urethra with a dry foley, why would you do it with the trachea?), don't try to pass the whole damn thing with the stylet still in, regardless of your view. When you use VL, you get the tube in but don't advance all the way until the stylet comes out. Same thing with dl. If you have a grade 1 view, you're looking straight into the trachea. A straight line. An ETT with formed stylet is only hurting you (unless of course it's perfectly straight). That being said, you don't know if you're gonna get a grade 1 when you start so a stylet is still probably justified. Get savvy with popping the stylet out with one hand and advancing. Alternatively, put the tip of the tube right at the cords and ask for the stylet to me removed slowly as you advance off and in. And as you already mentioned, if you're truly stuck on rings, twisting will get it through (and if it's lubed, it'll go right in).

 

[Velefunt]

It called reverse loading because the natural curve of the tube is in the reverse of the usual intubation position. You make your usual stylette bend, but the tube is loaded on reversed 180 degrees. If you can’t advance the tube into the trachea, after you engage the tip in the glottis, when you slowly remove the stylette, the tube will flex downward and assist in making the drop into the trachea.

Interesting technique; I'm gonna tuck this one away for that rare uncommon post-glottis resistance situation. Usually, I utilize a little downward tracheal pressure to help direct everything downward to facilitate these intubations, but a reverse-load might be interesting to try.

 

[ethilo]

The only time I ever routinely use a stylet is on infants and glidescopes due to it being indirect laryngoscopy. Otherwise I'll use it only in specific scenarios that seem like they would call for it (very rare). With good technique and getting used to it, you can intubate just about anything else without a stylet. It's one less step and/or one less thing to rely on someone else to help with so you can secure the airway quicker.

 

[Ronin786]

I agree with whoever said it seems physically impossible that you have a Grade I view with DL and cannot get the tube to the cords outside of size mismatch. I mean you have a direct line of sight to the cords, it's literally impossible unless there's an obstruction distally or the tube is too big.


With VL that's a different story.

 

[Lidolover]

Some of them tried to teach me that too in residency. Luckily, I had a badass OG attending who taught me that was nonsense.

I could not agree more with this.
During my first two months of CA-1 year, I would prep the room and when I would come in with the patient, I would always realize someone (actually my senior supervising resident) had made a hockey stick ETT...Always! He would say you only forgot this. LoL.
Man you can’t imagine how irritated I would be. From my experience with the hockey stick BS, if you want to sabotage someone, bend the ETT to a hockey stick. The dampest thing EvER

 

[nimbus]

I agree with whoever said it seems physically impossible that you have a Grade I view with DL and cannot get the tube to the cords outside of size mismatch. I mean you have a direct line of sight to the cords, it's literally impossible unless there's an obstruction distally or the tube is too big.


With VL that's a different story.

Agree. I’m sure it’s a technique issue. Maybe how they hold the tube.

 

[woopedazz]

I've only used a stylet twice. Not common here and rarely required. Bougie's are much kinder for the handler and patient when you need to railroad a tube in (In my opinion)

 

[coffeebythelake]

Agree. I’m sure it’s a technique issue. Maybe how they hold the tube.

I read somewhere that with a grade 1 CL view, there is a 99.5% of successful intubation.
So there is a 0.5% chance of "difficulty" -- almost certainly technique related?

 

[Gern Blansten]

I'm sure everyone has said this (but I'm too lazy to read all the posts): lube the tube (you don't intubate the urethra with a dry foley, why would you do it with the trachea?), don't try to pass the whole damn thing with the stylet still in, regardless of your view. When you use VL, you get the tube in but don't advance all the way until the stylet comes out. Same thing with dl. If you have a grade 1 view, you're looking straight into the trachea. A straight line. An ETT with formed stylet is only hurting you (unless of course it's perfectly straight). That being said, you don't know if you're gonna get a grade 1 when you start so a stylet is still probably justified. Get savvy with popping the stylet out with one hand and advancing. Alternatively, put the tip of the tube right at the cords and ask for the stylet to me removed slowly as you advance off and in. And as you already mentioned, if you're truly stuck on rings, twisting will get it through (and if it's lubed, it'll go right in).

User name checks out.