Intubation help

[Newyorkgiants]

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wanted to get some pointers on intubating. While using a Mac blade I am initially hooking the epiglottis. I then back out and the epiglottis falls into view. I push up and out and the epiglottis will not move at this point. Should I be advancing more to engage the vallecula. Should I initially be pushing up and out when first putting in the laryngoscope to avoid hooking the epiglottis or advance the laryngoscope and then push up and out. Any tips are greatly appreciated as this is frustrating.

Thanks

 

[Chloroform4Life]

Yes, you need to engage the vallecula more if you can. There is a ligament in the vallecula that as you press on it, will pull the epiglotis up and out of your way. Manipulating the larynx with your other hand can also help you engage the ligament better, then have your assistant hold the "cricoid pressure" the way you manipulated the larynx while you grab your tube and enter the glory hole.

 

[Doctor4Life1769]

The best thing I ever did was practice on a mannequin. I'm sure there's some YouTube videos too.

 

[skypilot]

Yes, you need to engage the vallecula more if you can. There is a ligament in the vallecula that as you press on it, will pull the epiglotis up and out of your way. Manipulating the larynx with your other hand can also help you engage the ligament better, then have your assistant hold the "cricoid pressure" the way you manipulated the larynx while you grab your tube and enter the glory hole.

Yes if you advance the MAC blade into the vallecula a little more the epiglottis will lift up like a trap door or like an old fashioned garage door. Don't try to use brute force to lift the epiglottis "up and out" just advance your blade a little and it should pop out of the way.

If patient has a huge head, a pendulous floppy epiglottis, and a deep airway you need that Mac 4, Miller 3, glidescope standing by, and plenty of preoxygenation so you can relax a little.

 

[Chloroform4Life]

 

[skypilot]

Beautiful picture! If you advance the blade all the way in there, the epiglottis will pop right up like a trap door. If you are halfway out it will hang down and obstruct your view and you may cause damage trying to lift it. Just advance the blade a bit.

 

[sigrhoillusion]

If you can't advance the blade farther in, your only other option is a retrograde intubation.

 

[Chloroform4Life]

If you can't advance the blade farther in, your only other option is a retrograde intubation.

You forgot the /s

There are other options:
Do case with LMA

Wake pt up for awake fiberoptic (very rare)

Fiberoptic with glidescope guidance.

Fiberoptic with LMA guidance.

Glidescope with bougie. Or just glidescope if you stared with normal DL.

Not saying that retrograde is not a good option, but its not the only option.

 

[sigrhoillusion]

You might need to change the batteries on your sarcasm detector...

 

[Chloroform4Life]

You might need to change the batteries on your sarcasm detector...

Haha I thought you were being sarcastic, but i can't tell on this forum. I've seen people offer some pretty outrageous opinions.

Don't forget, OP is likely a med student or young resident so he may take your advice literally. Can you imagine what his attending would say if he pulled out the retrograde wire after the initial DL?

 

[btbam]

Haha I thought you were being sarcastic, but i can't tell on this forum. I've seen people offer some pretty outrageous opinions.

Don't forget, OP is likely a med student or young resident so he may take your advice literally. Can you imagine what his attending would say if he pulled out the retrograde wire after the initial DL?

He'd probably be impressed that he even knows what the hell a retrograde wire is haha.

 

[Planktonmd]

If you can't advance the blade farther in, your only other option is a retrograde intubation.

😵

 

[criticalelement]

please dont trap the epiglottis underneath the mac blade. This is traumatic and almost sure to have complaints post-op. Too many of those complaints you will have walking papers. In other words, Thanks but no thanks doctor. We wont be needing your services come july.. You can avoid all this by gently placing the tip of the blade into the vallecula.. Its not a blind procedure. You have to see the epiglottis before engaging with the blade. If you dont see epiglottis.. usually you are in too far..

 

[Chloroform4Life]

please dont trap the epiglottis underneath the mac blade. This is traumatic and almost sure to have complaints post-op. Too many of those complaints you will have walking papers. In other words, Thanks but no thanks doctor. We wont be needing your services come july.. You can avoid all this by gently placing the tip of the blade into the vallecula.. Its not a blind procedure. You have to see the epiglottis before engaging with the blade. If you dont see epiglottis.. usually you are in too far..

Although I agree with not using the mac like a miller, I have never heard of an anesthesiologist fired for having too many patients with sore throat.

What about all those people using miller blades?

Though I admit that I am a Mac man myself and when I see someone use the Miller I think... why would someone use such a medieval device when a more refined instrument is available.

 

[pgg]

please dont trap the epiglottis underneath the mac blade. This is traumatic and almost sure to have complaints post-op.

I agree. Gentle is better.

Too many of those complaints you will have walking papers. In other words, Thanks but no thanks doctor. We wont be needing your services come july.

That's a little dramatic. If you're causing a rash of injuries then you're probably clumsy at everything else too, and maybe not going to be welcome to stay. Sore throats from hamfisted DLs are just bad style though.

 

[Newyorkgiants]

I'm just a med student with about 8 intubation attempts at this point. Any tips on how to end up on top of the epiglottis as I feel at I am always below it when first putting in the laryngoscope before backing out a bit