Intubating on pillows

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
Interesting how practices vary. We have very few donuts in our operating rooms so we all intubate on pillows. I don’t know anyone who specifically asks for a donut for intubation. They’re reserved for head and neck cases to stabilize the head. It’s been that way as long as I can remember. But nowadays many of us use glidescopes.
 
GassYous said:
Put it under the shoulders
Or just use a mcgrath
Click to expand...

I personally have felt that shoulder rolls have made intubation harder for adults (not kids obviously). We’re normally flexing the c-spine so the angles would be different compared to a shoulder roll right?

I remember trying to intubate for ENT, we used to leave the shoulder roll in but started taking it out and then replacing it once the tube was in.
 
Newtwo said:
Never once used donut for intubation or even seen it. Just give it a bit of a lift
Click to expand...

We use these:

IMG_5507.jpg


Works pretty well, just shove it in a little after inducing and you have a great sniffing position.
 
Most patients, I either put nothing under, or a sheet. For the big'uns I'm all about that ramp/back up w/ HOB folded back or back up with shoulder roll to give some neck extension. If there is a pillow, I rarely remove it unless I have airway concerns.
 
Take the pillow, roll it in half under the inferior c spine after you push the sux. The head will elevate and fall backwards, the jaw fall open, and the patient will be in the auto-sniffing position. I’ve been doing this for 5 years, rarely need a video laryngoscope. And it’s not like I’m some robed Kung Fu master of the airway. More the opposite.
 
coffeebythelake said:
2 blankets
Click to expand...
This.
Plus a few thousand tubes under your belt and you'll be grand...

Unfortunately there is no substitute for 1000s of intubations, i dont care who you are or how smart you are

The old school definition of a difficult airway used to include the words 'as described by traditionally trained anesthesiologist' ie done 5000 intubations

What im trying to get at is, and i dont know where you are in your career but to more junior folk... Keep up the practice and stay learning and listening and watching
 
Newtwo said:
This.
Plus a few thousand tubes under your belt and you'll be grand...

Unfortunately there is no substitute for 1000s of intubations, i dont care who you are or how smart you are

The old school definition of a difficult airway used to include the words 'as described by traditionally trained anesthesiologist' ie done 5000 intubations

What im trying to get at is, and i dont know where you are in your career but to more junior folk... Keep up the practice and stay learning and listening and watching
Click to expand...
I like this. It's the sensitive way of saying "GeT bEtTeR NoOb, LoL."
 
dmk5n said:
Reverse T-berg is money.
Gets the ears above the manubrium... boobs and pannus go down to the toes. opens up the lungs.
But sometimes, you gotta be Lurch to reach the airway.
make that circulator get a stool. FETCH!
Click to expand...

Why reverse T when you can bring back up to sitting position?
 
dmk5n said:
Reverse T-berg is money.
Gets the ears above the manubrium... boobs and pannus go down to the toes. opens up the lungs.
But sometimes, you gotta be Lurch to reach the airway.
make that circulator get a stool. FETCH!
Click to expand...

You got any digits?
 
Sniffing position or even beyond sniffing position(neck flexion with the head pushed forward as far as possible) aligns the oral-pharyngeal-laryngeal axis. The limitation of doing this is that it can decrease space within the oropharynx. I see many older folks doing the opposite. IE dont have a view and thus remove blanket/pillow head support leading to worsening view. They end up using the glide scope more than necessary.
 
I choose Reverse T-Berg over sitting more to buy myself more time rather than to change the mechanics of intubation. Greater FRC with reverse T-Berg - belly just falls with gravity vs being squished by the thighs and pushed up into the chest with sitting/reclined.
 
NoodleIncident said:
I choose Reverse T-Berg over sitting more to buy myself more time rather than to change the mechanics of intubation. Greater FRC with reverse T-Berg - belly just falls with gravity vs being squished by the thighs and pushed up into the chest with sitting/reclined.
Click to expand...

do u have any concerns about reducing venous return in this position? it seems like more of an issue than sitting position
 
coffeebythelake said:
do u have any concerns about reducing venous return in this position? it seems like more of an issue than sitting position
Click to expand...
Nah, like the other guy I use reverse T to optimize lung mechanics and positioning all the time. Just give some neo before the prop to squeeze that venous tone
 
coffeebythelake said:
do u have any concerns about reducing venous return in this position? it seems like more of an issue than sitting position
Click to expand...

I can’t say that I’ve noticed much difference in hemodynamics during induction between reverse T-berg and supine. But then again I’m using reverse T-Berg more in the morbidly obese bariatric population who are generally younger and perhaps more resistant to insult.
 
vector2 said:
View attachment 341905

It is shocking the degree to which the diagram above, which I thought was extremely well known, is actually unknown among so many "providers"
Click to expand...
I'm very familiar with it. I just don't find it necessary to perfectly position 80% of patients. Most are easy enough without any extra positioning. I just put the bed nice an high so i don't have to bend down at all.

The moment I have any concerns about the airway, I become very focused on good patient positioning.
 
abolt18 said:
I'm very familiar with it. I just don't find it necessary to perfectly position 80% of patients. Most are easy enough without any extra positioning. I just put the bed nice an high so i don't have to bend down at all.

The moment I have any concerns about the airway, I become very focused on good patient positioning.
Click to expand...
I don’t “perfectly” position everyone either. My point is I see a lot of people shove the donut or pillow under the neck and hyperextend the head instead of just leaving the donut in place and gently extending the neck, I.e. classical sniffing position.

Or they’ll pull the pillow out and of course I gotta put the pillow back in or lift the pt’s head to the position where it was in the damned first place
 
In my experience the block foam somebody pictured earlier and a pillow under the head make DL harder. I have more success when I push the pillow under the shoulders to flex the inferior cervical vertebrae too (it's still under the head too so not like a shoulder roll in pediatrics).
 
secretasianman said:
Ive unconsciously developed the habit of resting my right hand under the patient’s head and doing some gentle lifting. Sometimes I use my fat ass stomach as a third hand to prop the head up. I guess I’ve developed this technique after 5000 intubations.
Click to expand...
Seems common that the pannus skills grow in parallel to number of intubations.
 
secretasianman said:
Ive unconsciously developed the habit of resting my right hand under the patient’s head and doing some gentle lifting. Sometimes I use my fat ass stomach as a third hand to prop the head up. I guess I’ve developed this technique after 5000 intubations.
Click to expand...
I had a bit of a gut even before entering the midlevel anesthesia world. The stomach hand has been used for two years, especially with real fatties, and it won't ever stop. Off call now after 56 hours, finally able to maintain it. The SH, that is. Glad to see other users of that magnificent tool.
 
norski said:
I had a bit of a gut even before entering the midlevel anesthesia world. The stomach hand has been used for two years, especially with real fatties, and it won't ever stop. Off call now after 56 hours, finally able to maintain it. The SH, that is. Glad to see other users of that magnificent tool.
Click to expand...
No thanks... I make every effort to allow no part of my body, except my REAL hands, touch patients.
 
vector2 said:
I don’t “perfectly” position everyone either. My point is I see a lot of people shove the donut or pillow under the neck and hyperextend the head instead of just leaving the donut in place and gently extending the neck, I.e. classical sniffing position.

Or they’ll pull the pillow out and of course I gotta put the pillow back in or lift the pt’s head to the position where it was in the damned first place
Click to expand...
Pushing the foam pillow in under the neck increases both cervical spine flexion and atlanto-occipital extension... Now the right hand can be free for external laryngeal manipulation if needed. Sometimes I have lift the occiput more after doing that but it's uncommon.
 
norski said:
I had a bit of a gut even before entering the midlevel anesthesia world. The stomach hand has been used for two years, especially with real fatties, and it won't ever stop. Off call now after 56 hours, finally able to maintain it. The SH, that is. Glad to see other users of that magnificent tool.
Click to expand...

Stomach hand? At least you weren't referring to your third leg.
 
FiO2@21 said:
Pushing the foam pillow in under the neck increases both cervical spine flexion and atlanto-occipital extension... Now the right hand can be free for external laryngeal manipulation if needed. Sometimes I have lift the occiput more after doing that but it's uncommon.
Click to expand...
I guess it depends on the pillow but I think shoving pretty much anything in the direction of the cervical lordotic curvature worsens the view by causing too much occipital extension and minimal cervical flexion. Unless you've got some support under the occiput your position is gonna look more like the first guy and not the second in the diagram

F2.png
 
This is a good review of optimal positioning and (for the most part) the techniques I use when intubating

airwayjedi.com

Positioning The Head For Intubation

Patient position can make intubation easy, or hard. This article discusses how to obtain a good sniffing position to succeed in first pass intubation.
airwayjedi.com airwayjedi.com
 
vector2 said:
I guess it depends on the pillow but I think shoving pretty much anything in the direction of the cervical lordotic curvature worsens the view by causing too much occipital extension and minimal cervical flexion. Unless you've got some support under the occiput your position is gonna look more like the first guy and not the second in the diagram

View attachment 341956
Click to expand...

I’ve always been a pillow guy. You want 2 curves, flexion in the lower cervical vertebrae coupled with atlanto-occipital extension. The lower figure omits the atlanto-occipital extension. The upper figure omits the lower cervical flexion.

Anyway it’s all moot nowadays. Just VL.
 
nimbus said:
I’ve always been a pillow guy. You want 2 curves, flexion in the lower cervical vertebrae coupled with atlanto-occipital extension. The lower figure omits the atlanto-occipital extension. The upper figure omits the lower cervical flexion.

Anyway it’s all moot nowadays. Just VL.
Click to expand...
The blanket flexes the neck (to align the pharyngeal and laryngeal axes), but you still have to tilt the head back to get them to extend at the head into the sniffing position (to align the oral axis with the other axes):

axes-3.png


While I think VL makes intubation a lot easier, there are some situations where DL is superior.
It is demonstrably faster to DL an uncomplicated airway.
VL cameras can easily fog up or be covered with secretions.
 
secretasianman said:
Ive unconsciously developed the habit of resting my right hand under the patient’s head and doing some gentle lifting. Sometimes I use my fat ass stomach as a third hand to prop the head up. I guess I’ve developed this technique after 5000 intubations.
Click to expand...
This is the ONLY advantage of having a gut. 🙂
 
0kazak1 said:
Fold a blanket or a sheet.

Or get a pressure bag under the head as your pillow, and deflate when it’s time to intimate.
Click to expand...
Dang it! GassYous beat me to it.
coffeebythelake said:
ER intubations involve not checking BP or having pulse ox and intubating with 20 of etomidate and 100 suxx with no waiting. Of course they use the glidescope.
Click to expand...
I got pushback last week for not using Etomidate instead of lower dose propofol. But the guy was also wanting to intubate in a chair before he asked me for help bc the patient oxygenated better that way
secretasianman said:
Ive unconsciously developed the habit of resting my right hand under the patient’s head and doing some gentle lifting. Sometimes I use my fat ass stomach as a third hand to prop the head up. I guess I’ve developed this technique after 5000 intubations.
Click to expand...
And I guess you have also developed that technique after 5,000 Big Macs (speaking from experience)
 
I think all of us understand the importance of proper positioning. That being said - pillow, donut, foam block, whatever - does it matter that much for most cases? Most of mine are probably on a pillow. Comfortable for the patient. Take the hole out of the donut and the pt's head is resting flat on the bed so that's kind of pointless IMHO. If I need a better view, I just lift the head with my right hand while intubating with my left.
 
You must log in or register to reply here.

Similar threads

T
Awake Intubation
2
Replies
52
Views
5K
amyl
A
P
Remaining intubated post op
Replies
20
Views
2K
zizzer
Z
I
Advice on malpractice tail
Replies
14
Views
1K
AKMD_1984
A
Photoelectric19
advice on ranking programs
Replies
14
Views
1K
Katheudontas parateroumen
K
A
Dr G on private equity
Replies
1
Views
1K
PainInTheAnes
P
Top