Intubation question

[augmel]

So I am currently doing an anesthesia elective at the end of my internship and am trying to get good with different blades. I keep running into the same problem with the miller 2. I'm going down and then I see the epiglottis flopped down. I kind of subtly rotate the handle down towards the chest so that I can get the tip of the blade under the epiglottis and then bring it back into position at which time my attending thinks I am rocking the laryngoscope back and gets worried about them maxillary teeth. It then seems like as soon as I lift up on the handle the way I usually would with the mac that the epiglottis flops back down. I'm obviously not getting deep enough. When I watch my attendings, it seems like they just kind of plow over the epiglottis and lift up. Is there any risk of "breaking" the epiglottis or is it flexible enough that it can be scrunched into whatever shape by the blade and then pop back to normal? Any hints for better miller usage? Thanks, all.

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[The_Sensei]

So I am currently doing an anesthesia elective at the end of my internship and am trying to get good with different blades. I keep running into the same problem with the miller 2. I'm going down and then I see the epiglottis flopped down. I kind of subtly rotate the handle down towards the chest so that I can get the tip of the blade under the epiglottis and then bring it back into position at which time my attending thinks I am rocking the laryngoscope back and gets worried about them maxillary teeth. It then seems like as soon as I lift up on the handle the way I usually would with the mac that the epiglottis flops back down. I'm obviously not getting deep enough. When I watch my attendings, it seems like they just kind of plow over the epiglottis and lift up. Is there any risk of "breaking" the epiglottis or is it flexible enough that it can be scrunched into whatever shape by the blade and then pop back to normal? Any hints for better miller usage? Thanks, all.

Hints for Miller usage? Yeah, if you don't like using it don't. This whole concept of the Miller being the "go to blade" during a difficult intubation is nonsense. Become facile with a Mac-3 and you'll never need anything else.
My experience anyway.......

 

[The_Sensei]

So I am currently doing an anesthesia elective at the end of my internship and am trying to get good with different blades. I keep running into the same problem with the miller 2. I'm going down and then I see the epiglottis flopped down. I kind of subtly rotate the handle down towards the chest so that I can get the tip of the blade under the epiglottis and then bring it back into position at which time my attending thinks I am rocking the laryngoscope back and gets worried about them maxillary teeth. It then seems like as soon as I lift up on the handle the way I usually would with the mac that the epiglottis flops back down. I'm obviously not getting deep enough. When I watch my attendings, it seems like they just kind of plow over the epiglottis and lift up. Is there any risk of "breaking" the epiglottis or is it flexible enough that it can be scrunched into whatever shape by the blade and then pop back to normal? Any hints for better miller usage? Thanks, all.

Hints for Miller usage? Yeah, if you don't like using it don't. This whole concept of the Miller being the "go to blade" during a difficult intubation is nonsense. Become facile with a Mac-3 and you'll never need anything else.
My experience anyway.......

 

[psychbender]

If you're not getting the depth you need out of the Miller 2, why not go for the Miller 3?

Also, from my limited experience (MS1/medic), entering the mouth from the lower right side (with respect to you), going as deep as you can with the Miller 2, then pulling up and to the left (slowly), with the blade tip pointing to the left foot can give a decent view of the area, and let you know if you need to pull back a little, or need a longer blade. I probably described it rather poorly.

Regarding breaking the epiglottis, I haven't heard about this before. It generally takes a good bit of force and distortion to truly break elastic cartilage.

 

[burntcrispy]

Using the Miller is a completely differnet technique than using the Mac. I agree that you should get very proficient with the Mac before trying to swith to the Miller. I didn't start using the Miller until I'd already done about 150 intubations or so with the Mac.

When I intubate with a Mac, I go in looking for the epiglottis as I'm inserting the blade. Once I see it I put the tip of the blade into the vallecula then push towards the feet with a forward rocking type motion. I was taught this push toward the feet technique rather than up and out and it has worked well for me. Sometimes the Mac 3 isn't quite long enough and you may have to switch to the Mac 4.

With the Miller I put the tip towards the right tonsillar pillar then go in looking for the epiglottis. Once you see the epiglottis drop the blade a little, go in a little farther and gently lift up on the epiglottis. It's different that using the Mac where you have to kind of lift/push to get the epiglottis to "flip up". With the Miller you're just lifting the epiglottis out of the way. It doesn't requre any force. When you see the epiglottis you already have the angle you need so you shouldn't have to rock the handle backwards or anything. Just lift the epiglottis and the cords should be there. If you don't see the cords after lifting the epiglottis you've probably gone a bit too far. If this happens, slowly pull your blade back and you will see the cords. If you pull back too far the epiglottis will flop back down. The Mil 2 is long enough to intubate most patients. It's very rare that one will need to use the Mil 3. I've spoken to 4th year residents who still have never needed the Mil 3. So if the Mil 2 isn't working for you it is more likely due to technique than not being long enough. It takes practice but you'll get it.

Hope this helps.

 

[Carm]

I learned (and am learning) with a Miller 2. Have only used mac once. I have a crusty old attending that makes the residents in his room use a Miller 3 for every intubation. He says that he has never had an intubation that was done with laryngoscope that he couldn't get with Miller 3. He has had several where Miller 2 was not long enough. His theory is why not start with the end all be all (in his estimation).

Honestly, we hate having to use the Miller 3, it feels like you have a garden spade trying to find the cords. That's the problem with only using one blade (my precious Miller2) you get really comfortable with that blade.

 

[jetproppilot]

Hints for Miller usage? Yeah, if you don't like using it don't. This whole concept of the Miller being the "go to blade" during a difficult intubation is nonsense. Become facile with a Mac-3 and you'll never need anything else.
My experience anyway.......

Theres no such thing as "the right" blade.

Different clinicians continue to manage difficult intubations with whatever blade they are most deft with.

My residency chairman (a Brit) used a Mac3 for everything. And he could intubate an ant.

I prefer the Miller 2. I can intubate an ant with a Miller 2.

 

[jwk]

I prefer the Miller 2. I can intubate an ant with a Miller 2.

Or even a Miller 1. 😉

 

[psychbender]

When I was doing my OR hours for medic class, I was following this one anesthesiologist who said he used a Mac 4 on everyone. "If you don't need it all, just don't put it all in." I asked for the Miller 2 (what I always used on Fred the head in class) on the 18yom football player. His response, "Sure, you can go with that, what do I know, I've only been doing this since the seventies."

Still got the tube, but he handed me off to one of his CRNAs after that. Jerk.

Anyone here have any experience with the Grandview blades? I used one for the first time a few weeks ago, and thought it was great; though others on my squad have a very low opinion of them.

 

[Tenesma]

miller 2 or 3 - rocks all the way to the bank... if you think about it what does an ENT use for their airways? a straight blade... what does a thoracic surgeon use? a rigid straight scope...

the MAC is gentler on the patient, but if i smell trouble I ALWAYS go straight for the miller....

and for those in the know, the left molar approach has saved my butt many times

references:
Yamamoto K , et al. Left-molar approach improves the laryngeal view in patients with difficult laryngoscopy Anesthesiology 2000; 92:70–4
Sato N Another reason to choose the left molar approach of laryngoscopy: to spare the incisor teeth Anesthesiology 2002; 96:1279
Farler C The left molar approach assisting fibreoptic intubation Anaesthesia 2002; 57:1031-3

 

[jetproppilot]

So I am currently doing an anesthesia elective at the end of my internship and am trying to get good with different blades. I keep running into the same problem with the miller 2. I'm going down and then I see the epiglottis flopped down. I kind of subtly rotate the handle down towards the chest so that I can get the tip of the blade under the epiglottis and then bring it back into position at which time my attending thinks I am rocking the laryngoscope back and gets worried about them maxillary teeth. It then seems like as soon as I lift up on the handle the way I usually would with the mac that the epiglottis flops back down. I'm obviously not getting deep enough. When I watch my attendings, it seems like they just kind of plow over the epiglottis and lift up. Is there any risk of "breaking" the epiglottis or is it flexible enough that it can be scrunched into whatever shape by the blade and then pop back to normal? Any hints for better miller usage? Thanks, all.

Actually, the most important thing is to BE THE TUBE .

And as you're intubating, make the sound that Chevy Case made on Caddyshack when he was putting:

NEHNEHNEHNEHNEHNEHNEHNEHNEH.....

works every time.

 

[augmel]

Be the tube.... yeah.... that's it. I could have used that technique when the surgeon was standing there commenting about visits to the dentist when I barely touched the teeth. And I mean barely.

Thanks for the ideas. I think I'm gonna go back to the mac for a while and just make sure I am solid with that blade first.

 

[CambieMD]

I think that the best way to start out is to become very comfortable with one blade and then switch to another blade after you get comfortable with one blade say the mac for example. I started with the mac and began using the miller after about 180 intubations with the mac.

Cambie

 

[nimbus]

Be the tube.... yeah.... that's it. I could have used that technique when the surgeon was standing there commenting about visits to the dentist when I barely touched the teeth. And I mean barely.

Thanks for the ideas. I think I'm gonna go back to the mac for a while and just make sure I am solid with that blade first.

We have ED, podiatry, and medical residents coming through our department all the time. We wrap an alcohol pad, still in its foil wrapper, over the upper incisors. It's not as bulky as a dental guard and still protects the teeth from getting scraped or chipped.

 

[Monty Python]

I recently recertified at ACLS. The airway station instructor (professional qualifications unknown) told us: "If you intubate the esophagus on your first attempt, leave that ETT in place and try again. The ETT in the esophagus will show you where not to go with your next attempt."

Comments? Anyone use that technique?

 

[CambieMD]

What do you guys and girls use for a pt in a c-collar. I have used a mac or a bullard. Can a mller work in such a situation.

Cambie

 

[TofuBalls]

What do you guys and girls use for a pt in a c-collar. I have used a mac or a bullard. Can a mller work in such a situation.

Cambie

Miller and a bougie works great in this situation. All you need to see is the epiglottis. No cranking on the c-spine at all.

 

[jwk]

What do you guys and girls use for a pt in a c-collar. I have used a mac or a bullard. Can a mller work in such a situation.

Cambie

Depends on why they're in a C-Collar to begin with, and how quickly you need to secure an airway. If it's an unstable C-Spine, my first thought would be at least to consider awake FOB. Light wands aren't a bad thought for those that are adept at using them, nor are any of the intubating LMA's, fast-trak or otherwise. Although I've done lots of DL's on unstable C-Spine's, I think there are better ways to do it if you have the time. If not, MAC 3 for me, as I do on 99.9% of my cases. I use a straight blade once or twice a year just to say that I can when I really want to.

 

[12R34Y]

I recently recertified at ACLS. The airway station instructor (professional qualifications unknown) told us: "If you intubate the esophagus on your first attempt, leave that ETT in place and try again. The ETT in the esophagus will show you where not to go with your next attempt."

Comments? Anyone use that technique?

Takes me back to my old paramedic days. It's old school. Used to do it in the field back in the day all of the time. Lots did.

If you've got a cuffed tube in the esophagus your pretty much only going to get the next tube in the right spot (theoretically). Not a very sound argument. Also kept stomach contents from getting in the airway.

haven't seen it in years though.

definately wouldn't think it would be "taught" anymore.

later

 

[Noyac]

I recently recertified at ACLS. The airway station instructor (professional qualifications unknown) told us: "If you intubate the esophagus on your first attempt, leave that ETT in place and try again. The ETT in the esophagus will show you where not to go with your next attempt."

Comments? Anyone use that technique?

Thats what I tell the ER guys when they put it in the goose. I also tell them to inflate the cuff so when the pt barfs it goes past the cords, hopefully.

In my hands the MAC 4 works for everyone, "In My Hands".

 

[Monty Python]

.......
In my hands the MAC 4 works for everyone, "In My Hands".

It's interesting to read about the different choices of personal favorite blades.

I wonder: is it a by-product of biomechanical variations between individuals, teaching bias perceived while a resident/student, or "just because?"

My personal favorite (rarely mentioned) is the Phillips 2. Has all the benefits of the Miller 2, plus the upturned tip can act like a poor man's Mac when needed.

Anyone use the Mac 3 with the extra "squeeze handle" which actuates the movable flip-tip?

 

[NYCDawg81]

.

 

[Tenesma]

trust me if you put the ETT in the goose by mistake - it is better to leave it there until the trachea is secured.... cause if the pt vomits at least it will shoot in the air all over you instead of into the lungs... some people will actually stick an extra suction onto the goosed-ETT just to be on the safe side...

 

[augmel]

seems like one tube in the mouth obscures your view enough that two would really make it impossible. Never seen the "leave it in the goose" technique used.

 

[Jacads]

The bullard scope??? that is so 90's get a glide scope and cross that bridge to the 21st century. The Wisconsin #3 blade is the answer to all your intubating needs. Much better than a miller if jet can intubate an ant with a miller he could intubte an ant preemie with a Wisconsin blade.

 

[jetproppilot]

if jet can intubate an ant with a miller he could intubte an ant preemie with a Wisconsin blade.

HAHAHAHAHAHAHHAHAHAHAHAHHAHAHHAHAHAHHA


thats funny i don't care who you are thats funny