Intubation tips for a floppy epiglottis?

[Varmit22]

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Any intubation tips for people with a "floppy" epiglottis? With a miller, I pick up the epiglottis, but then it will obstruct my view of the cords. I'll try to ease back a little, but then will lose the epiglottis completely. This cycle repeats itself until dumb luck sets in or the attending takes over. Any tips are appreciated. Thanks.

 

[Lonestar]

take some scissors and snip it. oh and make sure you have a basket for catching it. 😀

sorry, got carried away. Miller is the way to go here. Just become facile at using miller blades. It will just take time, patience, and a little bit of luck. Try some cricoid pressure or maneuver (BURP)which allows you to bring the cords into view while using the miller.

 

[toughlife]

Any intubation tips for people with a "floppy" epiglottis? With a miller, I pick up the epiglottis, but then it will obstruct my view of the cords. I'll try to ease back a little, but then will lose the epiglottis completely. This cycle repeats itself until dumb luck sets in or the attending takes over. Any tips are appreciated. Thanks.

Miller blade

 

[Tenesma]

get a gum-elastic bougie - and slip it past the miller - during my training and thereafter i always had a bougie ready to go within hand-grasp... a life-saver more than once, and it always draws some oohs and ahhs.

 

[SleepIsGood]

Put the stylet past the endotracheal tube when you make it into a 'hockey stick'. Yes I know everyone tells you NOT to put the stylet past the ET tube...however, if you do that you've essentially created a bougie.

NEver done this..but an attending was telling me that's what he does.

 

[CremeSickle]

Another option is to use the Mac like a miller. If this is an adult then a Mac 4 if a kiddo then a mac that fits the age. Place the mac under the epiglottis and pick it up like you would a miller. It provides the same function but will keep the epiglottis out of your way easier.

This option can be your backup until you get more practice with the miller.

 

[VentdependenT]

Agree with bougie.

You can also use your mac 4 in a miller type fashion to pick up the epiglottis. Sometimes it affords you more room. If not, ask someone to pull the right cheek and lips laterally to give ya more room for the tube.

 

[Arch Guillotti]

Put the stylet past the endotracheal tube when you make it into a 'hockey stick'. Yes I know everyone tells you NOT to put the stylet past the ET tube...however, if you do that you've essentially created a bougie.

NEver done this..but an attending was telling me that's what he does.

A couple of times for emergent floor intubations I have loaded the ET tube with the bougie as a stylet, worked great each time.

 

[beezar]

Any intubation tips for people with a "floppy" epiglottis? With a miller, I pick up the epiglottis, but then it will obstruct my view of the cords. I'll try to ease back a little, but then will lose the epiglottis completely. This cycle repeats itself until dumb luck sets in or the attending takes over. Any tips are appreciated. Thanks.

When I was learning the Miller blade, I did the same thing, over and over again til I wanted to shoot myself. Two things that helped:

1) after picking up the epiglottis, I wouldn't be able to see the cords. Gently pressing on the tracheal cartilage without moving the blade often dropped the cords into perfect view

2) lots and lots and lots of practice. I soon got facile with the Miller blade and could pick up the epiglottis and view the cords without doing step I after many many intubations. the real trick is paying attention to and controlling the tongue.

 

[Frank Rizzo]

Another option is to use the Mac like a miller. If this is an adult then a Mac 4 if a kiddo then a mac that fits the age. Place the mac under the epiglottis and pick it up like you would a miller. It provides the same function but will keep the epiglottis out of your way easier.

This option can be your backup until you get more practice with the miller.

I did this exact maneuver yesterday when I was paged to the floor to intubate some CCU player in resp distress. Not the first time I've done it that way. Works well.

 

[Idiopathic]

A couple of times for emergent floor intubations I have loaded the ET tube with the bougie as a stylet, worked great each time.

This is brilliant. I have never thought of this.

I have used the ETT as a semi-bougie, however, and lifted up the epiglottis with the ETT to see the cords. Has worked a few times when I was frustrated with the view.

 

[Lonestar]

one of my attendings wouldn't let me intubate adults without a miller 3. well i got real facile with it quick (well still had trouble with some patients, ended up waking the pt up). so if you don't have an attending that does that, just let it be your personal goal of intubating pts with miller 3 for the first month ( no ifs, ands or buts).