I Love the miller blade - Seeking more mastery

[ISoNitrous]

Hey everyone,
After being in a supervisory role for over a year, I realize I need to keep my chops in top shape. I have three finer style points that I wanted to see if anyone could weigh in on regarding use of a Miller.

1. Proper sniffing position vs. head extension - when seeing ENT do their suspended laryngoscopy (as well as occasionally in my own experience), lots of head extension seems best. Other times I feel like sniffing position works perfectly. Other than the obvious - try one and make adjustments if needed...what head positioning to you prefer?

2. I usually use more of a paraglossal approach as described by JJ Henderson. But in any mouth that's not huge, I have a hard time finding any real estate near the right molars, as my hand that's scissoring open the mouth is occupying that space. Anyone run into this/have an elegant solution?

3. Every once in a while, I've run into someone in whom I can visualize the epiglottis, but can't "cut the angle," so to speak, to get underneath it. Almost like I can just reach it orthogonally with the blade (epiglottis is in a vertical plane with the blade in a horizontal plane), but would have no hope of lifting it. Tips?

Thanks for the tutelage.

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[deleted162650]

A). Don’t scissor open the mouth. There’s no need to put your fingers in the mouth for a routine DL. As you extend the neck, the mouth will crack open. Slip the tip of the blade in and use a little forward pressure as you advance to open the mouth with the blade as you go.

B). Use a Mac blade.

 

[jwk]

This too shall pass. 🙂

 

[coffeebythelake]

I dont use Miller blade

 

[GassYous]

I rarely scissor open the mouth. I preox while the nurse does her stuff but don't bag the patient. I usually just push the prop, then the roc and tube as soon as I stop seeing the patient breathing.

For miller I just go in all the way on the right side of the mouth and go straight in until I see cords. Usually you need a little anterior tilt at the end to lift the epiglottis. Use a miller 2. It's a lot harder to do with an unstyleted tube. But these days my go to is the mcgrath 3.

 

[coffeebythelake]

I rarely scissor open the mouth. I preox while the nurse does her stuff but don't bag the patient. I usually just push the prop, then the roc and tube as soon as I stop seeing the patient breathing.

For miller I just go in all the way on the right side of the mouth and go straight in until I see cords. Usually you need a little anterior tilt at the end to lift the epiglottis. Use a miller 2. It's a lot harder to do with an unstyleted tube. But these days my go to is the mcgrath 3.

Your pt does a lot of bucking when u intubate?

 

[GassYous]

Your pt does a lot of bucking when u intubate?

It's actually pretty rare. I'd guess under 10%. Seems like it's in the healthy young people.

 

[deleted697535]

What's a Miller blade?
Whats a supervisory role? What is scissoring open the mouth, who is Henderson?

Mac 4, Lift more, glidescope. Thats pretty much it
Stuff 1 flannel under the top of shoulder blades for positioning, which is kinda what ENT do

 

[coffeebythelake]

It's actually pretty rare. I'd guess under 10%. Seems like it's in the healthy young people.

If u are intubating right when pt goes apneaic then I imagine u didn't give it enough time to work OR you are giving mega doses

 

[GassYous]

If u are intubating right when pt goes apneaic then I imagine u didn't give it enough time to work OR you are giving mega doses

Roc 50 just like everyone else. Try it. Views are fine 90% of the time, I don't even stylet the tube. Started it after I read about it here and no issues so far. Of course I'm not doing this for the bmi 50, etc. airways.

 

[Consigliere]

Jesus. Use a Glidescope or any other video laryngoscopy of your choosing. Done!

 

[deleted697535]

Roc 50 just like everyone else. Try it. Views are fine 90% of the time, I don't even stylet the tube. Started it after I read about it here and no issues so far. Of course I'm not doing this for the bmi 50, etc. airways.

One of my old staff used to do it and i disliked it. Its not about the view so much as forcing a tube through cords that arent relaxed. That cant be good... I see almost no benefit to it, and lots of harm. Ive seen too much vocal cord damage in my short career...

As has already been said this isnt bmi 50 nor rsi so why?


Wait 45 more seconds, give priming dose of roc, use remi... Surely there are better options than ramming a tube home.

 

[deleted697535]

Jesus. Use a Glidescope or any other video laryngoscopy of your choosing. Done!

Yeah honestly miller McCoy bullard lighted stlyet bla bla bla. Theyre dead and gone... Sorry...

There is only mac, vl and fob now

Dare i say it but dl with mac might die too... It will take 20 years but maybe?

 

[woopedazz]

I sometimes reach for a Miller when I have a bad view, but I thought you guys normally just called for the nearest CRNA when you had a bad view?

 

[CodeBlu]

I learned to use a Miller 4 with a bougie, tube pre-loaded. Someone holding MILS... especially if it's a bloody airway and video techniques don't work. I thought it was BS... until it happened to me, where I couldn't see with the glidescope. So basically, get the miller 4 in there, get a grade 3 view. Doesn't take much force. Bougie. Tube. My N is 2.... worked both times. Nifty to have in back pocket though.

 

[DrZzZz]

I learned to use a Miller 4 with a bougie, tube pre-loaded. Someone holding MILS... especially if it's a bloody airway and video techniques don't work. I thought it was BS... until it happened to me, where I couldn't see with the glidescope. So basically, get the miller 4 in there, get a grade 3 view. Doesn't take much force. Bougie. Tube. My N is 2.... worked both times. Nifty to have in back pocket though.

There is almost zero need for a Miller 4. Even a 3 is rarely necessary, but a 4 is just ridiculous.

 

[GassYous]

One of my old staff used to do it and i disliked it. Its not about the view so much as forcing a tube through cords that arent relaxed. That cant be good... I see almost no benefit to it, and lots of harm. Ive seen too much vocal cord damage in my short career...

As has already been said this isnt bmi 50 nor rsi so why?


Wait 45 more seconds, give priming dose of roc, use remi... Surely there are better options than ramming a tube home.

Pretty good point. Usually the cords are wide open but I have noticed them quivering a little a time or two. I haven't had any issues so far. I just don't like bagging when it seems like everyone and their grandmothers has covid now, even though we test every patient and think sux is unnecessary.

 

[DrOwnage]

I was able to get a better view with a miller after a mac attempt just the other day, albeit this is the first time that's happened. Was a tiny old lady, pulmonary cripple with white out of her right left (it was blood, surprise). Grade 3 view, MAC3 with a floppy-ass epiglottis and was too hard to feed the 8.0 tube up there in this small lady. I'm usually able to get a styleted tube in with a grade 3. Got a grade 1 with the miller after lifting that epiglottis up.

 

[DocVapor]

I was able to get a better view with a miller after a mac attempt just the other day, albeit this is the first time that's happened. Was a tiny old lady, pulmonary cripple with white out of her right left (it was blood, surprise). Grade 3 view, MAC3 with a floppy-ass epiglottis and was too hard to feed the 8.0 tube up there in this small lady. I'm usually able to get a styleted tube in with a grade 3. Got a grade 1 with the miller after lifting that epiglottis up.

Me too. Old smoker with epiglottic mass big enough to obscure the view using my normal Mac 3. Came in from right side with a Miller 2 and got it physically out of the way and Grade 1 view.

 

[Bryan O’Blivion]

Find Miller 2 useful in a patient with short thyromental distance. Find Mac 3 better in patients with big tongues, jowls etc. Miller 2 inserted to right of epiglottis creates pretty straight shot without a lot of manipulation. If you want to practice DL from either hand or side of the face, there’s a flattish Miller variant called the cranwall. Still awkward, but not actively designed to be restricted to a single approach. Pretty rarely find Mac 4 or Miller 3 useful, but there are some cases. VL is great until it’s not.

 

[Iso4ane]

When they open their mouths and stick out their tongue for airway assessment, I just stick the tube in then.

 

[DocVapor]

When they open their mouths and stick out their tongue for airway assessment, I just stick the tube in then.

You sneaky b*****d, you.

I love it.

 

[deleted875186]

I too have noticed more extension is helpful for miller, but good sniffing is always ideal for MAC.

 

[coffeebythelake]

Roc 50 just like everyone else. Try it. Views are fine 90% of the time, I don't even stylet the tube. Started it after I read about it here and no issues so far. Of course I'm not doing this for the bmi 50, etc. airways.

My biggest worry isn't that you wouldn't be able to intubate it is that the patient might vomit in the process

 

[nimbus]

Roc 50 just like everyone else. Try it. Views are fine 90% of the time, I don't even stylet the tube. Started it after I read about it here and no issues so far. Of course I'm not doing this for the bmi 50, etc. airways.

My biggest worry isn't that you wouldn't be able to intubate it is that the patient might vomit in the process

@GassYous may have read one of my posts. I actually mix the roc with propofol and lidocaine in the same syringe and give it all at once. It works every time for me. Nobody coughs or vomits. I glidescope just about everybody with teeth these days.

 

[Velefunt]

Yeah honestly miller McCoy bullard lighted stlyet bla bla bla. Theyre dead and gone... Sorry...

There is only mac, vl and fob now

Dare i say it but dl with mac might die too... It will take 20 years but maybe?

I guess you don't work at too many surgery centers where they get frown-y about overhead costs. It's gonna be re-usable LMA's and laryngoscopes till the day I retire.

 

[GassYous]

@GassYous may have read one of my posts. I actually mix the roc with propofol and lidocaine in the same syringe and give it all at once. It works every time for me. Nobody coughs or vomits. I glidescope just about everybody with teeth these days.

That sounds right, I'm pretty sure it was you. I use two syringes because I use the 10 cc syringe to inflate my tube and I use the other syringe to give any other meds in the case I need like zofran or reversal.

 

[Status Sciaticus]

I guess you don't work at too many surgery centers where they get frown-y about overhead costs. It's gonna be re-usable LMA's and laryngoscopes till the day I retire.

It costs less to buy a macgrath blade than the disposable DL. It costs more to resterilize a VL Glide than using the disposable one.

 

[coffeebythelake]

I guess you don't work at too many surgery centers where they get frown-y about overhead costs. It's gonna be re-usable LMA's and laryngoscopes till the day I retire.

Reusable LMAs? Haven't seen one of those in forever. Many surgicenters also use desflurane...

 

[deleted162650]

Reusable LMAs? Haven't seen one of those in forever. Many surgicenters also use desflurane...

Yes, we offset the cost of desflurane with reusable LMAs.

 

[GassYous]

Des is not as bad when the flows are low. But low flow iso is king.

 

[coffeebythelake]

Des is not as bad when the flows are low. But low flow iso is king.

Thats true for all low flow agents. That's why I use low flow all the time and cringe when a patient needlessly receives 10L sevo mask ventilation to "get them deeper" before airway instrumentation. For equipotent dose at same flow technique, desflurane generates much more GHG compared to sevo and is also much more expensive.

 

[Velefunt]

It costs less to buy a macgrath blade than the disposable DL. It costs more to resterilize a VL Glide than using the disposable one.

If we're using reusable LMA's why would you think they'd be paying for disposable laryngoscope blades? It's also funny you assume they're providing Glidescopes. I'll even up the ante with the plastics office that only provides isoflurane.

 

[GassYous]

If we're using reusable LMA's why would you think they'd be paying for disposable laryngoscope blades? It's also funny you assume they're providing Glidescopes. I'll even up the ante with the plastics office that only provides isoflurane.

I only use iso. Patients wake up on a dime.

 

[Velefunt]

Reusable LMAs? Haven't seen one of those in forever. Many surgicenters also use desflurane...

I'll regale you with a "funny" story - the first time we hired a new generation of anesthesiologists who'd never seen a reusable LMA in training, they managed to throw away >$10K worth of reusable LMA's their first month at the surgery center.

Edit: I haven't seen desflurane since residency.

Edit2: Come to think of it, might have been their first week at the surgery center they threw out $10K worth of the LMA's.

 

[Velefunt]

I only use iso. Patients wake up on a dime.

My point is the "cost saving" measures some offices and surgery centers take to save a buck.

 

[chocomorsel]

I'll regale you with a "funny" story - the first time we hired a new generation of anesthesiologists who'd never seen a reusable LMA in training, they managed to throw away >$10K worth of reusable LMA's their first month at the surgery center.

Edit: I haven't seen desflurane since residency.

Edit2: Come to think of it, might have been their first week at the surgery center they threw out $10K worth of the LMA's.

And the OR nurses let them do that? What kind of crappy OR nurses do you have? They should be on this stuff.

 

[Drwine]

If you live somewhere that had snow this weekend then go down your street with a snow shovel and offer to shovel all of your neighbors front steps. Once you do that you will have the right arm motion to master the Miller blade and realize it isn't a crowbar.🤣 Everyone laughs at this but the medical students and novice residents pick it up quickly when I give them this talk before attempting the Miller. I notice that most novices are timid and "dip and dive" and let the tongue get under the blade which kills the view.

 

[GassYous]

If you live somewhere that had snow this weekend then go down your street with a snow shovel and offer to shovel all of your neighbors front steps. Once you do that you will have the right arm motion to master the Miller blade and realize it isn't a crowbar.🤣 Everyone laughs at this but the medical students and novice residents pick it up quickly when I give them this talk before attempting the Miller. I notice that most novices are timid and "dip and dive" and let the tongue get under the blade which kills the view.

Relevant location

 

[Iso4ane]

Example of how to position patients for the Miller blade...

 

[chocomorsel]

If you live somewhere that had snow this weekend then go down your street with a snow shovel and offer to shovel all of your neighbors front steps. Once you do that you will have the right arm motion to master the Miller blade and realize it isn't a crowbar.🤣 Everyone laughs at this but the medical students and novice residents pick it up quickly when I give them this talk before attempting the Miller. I notice that most novices are timid and "dip and dive" and let the tongue get under the blade which kills the view.

Where is the tongue supposed to go? It always gets in my way and therefore I never use Millers unless it is pediatrics.

 

[vector2]

Where is the tongue supposed to go? It always gets in my way and therefore I never use Millers unless it is pediatrics.

 

[chocomorsel]

View attachment 325382

View attachment 325381

Except it always flops to the middle and never stays to the side as easily as a Mac. I assume because the blade is so thin. I stopped trying very early on as a CA1.
Why make stuff difficult when you don’t have to? And the length alone turns me off. It makes it very easy for me to possibly injure someone.

 

[dhb]

And the length alone turns me off. It makes it very easy for me to possibly injure someone.

Welcome to the club.

 

[vector2]

Except it always flops to the middle and never stays to the side as easily as a Mac. I assume because the blade is so thin. I stopped trying very early on as a CA1.
Why make stuff difficult when you don’t have to? And the length alone turns me off. It makes it very easy for me to possibly injure someone.

I don’t have any problem getting the tongue out of the way when going paraglossal, even with big floppy tongues (stay way more to the right of the mouth than you think is necessary). But ultimately just use whatever blade you’re most comfortable with.

 

[abolt18]

Literally just did the paraglossal approach with the miller 2 for the first time. 300lbs 49yo woman. DL with Mac3, barely see the tip of the epiglottis despite multiple manipulations of the blade, the tongue, the head, and the thyroid cartilage. Nothing improved the view.

Switch to miller, inspired by this thread, I went WAAAAAY right. Grade 1 view. Pretty sweet.

 

[Drwine]

Except it always flops to the middle and never stays to the side as easily as a Mac. I assume because the blade is so thin. I stopped trying very early on as a CA1.
Why make stuff difficult when you don’t have to? And the length alone turns me off. It makes it very easy for me to possibly injure someone.

Let me put it another way. Would a golfer use a driver, 5 iron, 9 iron, pitching wedge and putter in the same fashion?????? You need to learn a different technique to optimally use the Mac, Miller and Glidescope to best advantage. One technique doesn't fit all and the more techniques you can do effectively the more you will be successful and the more your patients will benefit.

 

[chocomorsel]

Let me put it another way. Would a golfer use a driver, 5 iron, 9 iron, pitching wedge and putter in the same fashion?????? You need to learn a different technique to optimally use the Mac, Miller and Glidescope to best advantage. One technique doesn't fit all and the more techniques you can do effectively the more you will be successful and the more your patients will benefit.

Glide scope to the rescue.
I know nothing about Golf. Nothing.

I am not that motivated to learn this. Lost that about 12 years ago.
Maybe one day after all this Covid crap when I am bored.
Right now ain’t the time to experiment w airway.

 

[Twiggidy]

 

[hankbb02]

I don't use the Miller for two reasons.
1) Why get the metal closer to the cords than you need to? Using a Miller blade increases the likelihood of trauma and edema of the cords. This is especially true in learners who insert the blade too deep to start.
2) MAC intubations look smoother than Miller intubations. After supervising for a year and watching experienced CRNAs readjust the blade multiple times to pick up the epiglottis it became clear that MAC had improved speed and better optics. I rarely have to optimize the positioning with a MAC blade and non-styletted tube curved in a loop.