Intubation tips?

[SBL]

Hi,

Sorry to bother everyone with a technical question. I know that match issues are a higher priority now, but if anyone wants to give me some advice, I'd appreciate it.

I'm a fourth year student (matched in OB/GYN, not going into anesthesia), and I'm doing an Anesthesia elective right now. I'm trying to get the hang of intubating, and I've succeeded a couple of times, but I still seem to have trouble lifting the laryngoscope the right way. I'll see the epiglottis and think I have it in the valeculae, but I can't seem to lift it the right way to get the vocal cords into view. That's where I'm stuck right now. I'm determined to get this right before the end of my rotation.

If anyone has any basic tips that worked for them, let me know-
Thanks,
-SBL

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[UTSouthwestern]

I guess from the beginning:

1. Tuck/extend the head/neck to align the oral pharyngeal and laryngeal axes.
2. Use your right hand to maximally open the mouth by using your thumb and first finger at the molars of the patient to "scissor" open the mouth.
3. Place the blade gently in the mouth on the right side of the tongue and then maneuver the blade toward the midline, sweeping the tongue to the left side of the mouth as you do so.
4. Lift the handle and blade up and away from you. If you see nothing, you have likely hooked the epiglottis which is OK if you are using the Miller/Phillips/other straight blade, but not good if you are using a MacIntosh blade. Slowly withdraw the blade while maintaining your up and forward lift and the vocal cords and epiglottis should drop into view.
5. You can sometimes change the angle of your lift slightly to lift the epiglottis up to expose the vocal cords, but don't rock back and touch/crack the upper incisors.
6. Good cricoid pressure (pressure posteriorly and cephalad on the cricoid cartilage WITHOUT pinching the laryngeal apparatus which obliterates the laryngoscopist's view) is priceless.
7. If the epiglottis is really long and floppy and you don't have time to switch to a straight blade, have the surgeon or nurse give you a chest compression to blow the epiglottis up for a second to allow you to quickly pass the tube.

Just the basics. The more esoteric techniques are numerous and too detailed for a short post.

 

[medic170]

Be sure not to tilt the blade back while lifting(as in on a fulcrum). Push up and out simultaneously and it wont slip from the tip of the blade (if you are using a Miller).

 

[SleepyTime]

Do you actually move the tongue over? So the blade going over the 'side' of the tongue, not the tip?

 

[wood]

I too am having trouble conceptualizing this concept of placement and "sweeping the tongue". Are there any good websites demonstrating this part?

 

[jetproppilot]

I too am having trouble conceptualizing this concept of placement and "sweeping the tongue". Are there any good websites demonstrating this part?

If you're using a Mac, after you put it in the righ side of the mouth, its designed to keep the tongue to the left.
This came to fruition for me in residency when I put the Mac3 in one time just like always...and it didnt work...guess what...there are Macs out there designed for left handed people!!! (which I guess they hold with their right hand).
Havent seen one of those since.

 

[powermd]

A technique that I learned today that made a huge difference in my intubating skills (on all three remaining cases..) was to do the following: After scissoring open the mouth, inserting the Mac blade, sweeping the tongue to the left, and finding the epiglottis- I learned to release the jaw (my scissor fingers), then adjust the head height with my (now free) hand until the cords came into view. I couldn't believe what a difference this made. I can't wait to to try this on some challenging patients.

 

[VentdependenT]

A technique that I learned today that made a huge difference in my intubating skills (on all three remaining cases..) was to do the following: After scissoring open the mouth, inserting the Mac blade, sweeping the tongue to the left, and finding the epiglottis- I learned to release the jaw (my scissor fingers), then adjust the head height with my (now free) hand until the cords came into view. I couldn't believe what a difference this made. I can't wait to to try this on some challenging patients.

If you see just the tip of the epiglottis in a grade 3 view make sure you have a nice "hockey stick" bend at the posterior end of your tube via a stylette and sneak that b!itch in there. Slip it under the epiglottis and slowly advance with some anterior force. You may intubate the esophagus but you may also save the day.

I still have a TON to learn though.

 

[supahfresh]

just did an intubation up in the unit and it was sweet. only one werid thing...I had a great view of the cords, but the light from the blade was shining into the epiglottis, not on the cords which I saw perfectly, albeit dark. I've never seen that before. Was this just a cheap blade?

 

[coop528]

Good tips guys.

I also have been having troubles getting the cords in view. How exactly do you sweep the tongue to the left. Recently, all my patients seem to have huge tongues and sweeping it is much easier said than done. Whenever I am lifting, I always have some of the tongue underneath the blade...therefore obstructing my view.

Help??

 

[UTSouthwestern]

Good tips guys.

I also have been having troubles getting the cords in view. How exactly do you sweep the tongue to the left. Recently, all my patients seem to have huge tongues and sweeping it is much easier said than done. Whenever I am lifting, I always have some of the tongue underneath the blade...therefore obstructing my view.

Help??

Like Jet said, the way to sweep the tongue to the left is to insert the blade to the right of the tongue with the flat of the blade and handle angled about 20-30 degrees left of midline. You then move the blade and tongue toward the left and once the blade is at the midline, lift up and away from the patient in the vertical plane. Make sure you tuck the head to get maximal mouth opening and to align the oral, pharyngeal, and tracheal axes.

 

[ppisklak]

Here is a cool video that shows an endotracheal intubation. Not sure how much it will help, but it is a really well-done animation.

http://www.youtube.com/watch?v=bqrgz7JgDrg

 

[rmh149]

Here is a cool video that shows an endotracheal intubation. Not sure how much it will help, but it is a really well-done animation.

http://www.youtube.com/watch?v=bqrgz7JgDrg

Wow....15ml of air in the cuff?

 

[fval28]

one of the tips i found most helpful when in training was to envision the intersection of the wall and ceiling on the other side of the OR from you- when lifting with your laryngoscope- push and lift the end of the handle away from you toward that intersection, that usually corrected me enough to make the force I was exerting follow the correct plane, get a good view of the cords, and kept me off the front teeth.

 

[epidural man]

After scissoring open the mouth.....

People still use that scissoring technique???? Wow. I try to keep my fingers out of other peoples mouth as much as possible.

 

[Jeff05]

i would not worry if you are having difficulty intubating. airway managment is complex and proficiency comes with A LOT of experience. as an OB-GYN you will NEVER have to intubate someone (if you do, you will likely cause more harm than good). focus on your mask ventilation skills - those are a must for anyone.

 

[The_Sensei]

Wow....15ml of air in the cuff?

Shut up.

 

[rmh149]

Shut up.

You are such an idiot.

 

[The_Sensei]

You are such an idiot.

You're opinion means nothing to me as you are a CRNA and therefore inferior in my mind.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[The_Sensei]

You are such an idiot.

.

 

[MS05']

Are you guys aware of any (reasonably priced) intubation videos/DVDs? The airway course http://www.theairwaysite.com/wordpress/ looks pretty sweet....but I can think of much much much better ways to spend 1 grand...that's a lotta freakin beer....

 

[RickKane]

Some may argue this, but for a novice I think it is much easier to lift if you firmly grip the handle of the laryngoscope. Some prefer to grip the scope closers to the blade really only using a couple of fingers. This is helpful for correct placement of the scope and sweeping the tongue out of the way but when you need to lift, try sliding your hand up on the handle, but be careful with your hand higher on the handle there will be more temptation to rock backwards.

 

[BobBarker]

I'm also having trouble "sweeping" the tongue and inserting the blade in the mouth optimally. When I position the head, the tongue flops back on the palate and I find myself reaching in with my left hand to move the tongue caudad so I can get the blade past it. I'm eventually getting the vallecula most of the time, but I am then having a difficult time getting a good view. I think I'm doing a good job of "pointing" to roof/wall intersection. Today, I was 0/4. 1 esophagus (saw the cords, inserted tube, so epiglottis tip down blocking view, and pushed tube into the esophagus), 2 no views, and 1 I saw the cords fine, but was having trouble getting the tube to slide in.