is "burying the blade" poor technique?

[heathermed]

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I've adopted the "burying the blade" technique for intubating where I put the blade in as much as possible at first and then come back till the epiglottis flops down. So far in my rotation, this has worked for me after one of my earlier attendings suggested it.

Yesterday, a new attending that I've never worked with scolded me for doing that because he said that it was poor form and may lead to unnecessary damage.

So I was curious... is this considered poor technique? Is the way where you advance slowly instead of backing up better?

I don't want to develop any bad habits... thanks for your input.

 

[dhb]

It's certainly not the most common technique but if it works for you...
The problem i see is that in patient that have a a long mouth to epiglottis distance you might never see the epiglottis drop back into view.

 

[Planktonmd]

There is nothing wrong with this technique and it does work.
Don't worry about what that attending said to you, he most likely has issues that he needs to work on.

 

[Doctor4Life1769]

I adopt a similar technique. I found if I don't and I try to "look for the cord" on the way down I don't go down enough ... so I tend to take it a little deeper and then come up and I can spot the cord and drop the tube.

 

[Ronin2258]

I try not to use it in humans.

It is a method that I usually reserve for intubating animals in research. with such a straight neck anatomy and most quadropeds (pigs, rats, mice,) have such floppy neck/trachea tissue, it is the easiest to use in animals. (Miller's blades all around in this instance, too.)

 

[InductionAgent]

I would not go overboard in your goal of deeply inserting the blade, but I think "burying the blade" is essentially good technique. It sounds like you are using a Mac blade. Especially in patients with smaller mouth openings, it is easiest to advance the blade deeper when you are first placing the blade inside the patient's mouth, on the right side. After sweeping the tongue and bringing the blade midline, it is easy to pull the blade back. However, if you grossly underestimate the required depth, it can be difficult to advance the blade farther, because the tip of the blade can get caught on the base of the tongue, and it will fold back on itself as you try to advance. In that case, you have to start over again and place the blade deeper. If you only slightly underestimate the required depth, it is easier to advance the blade after sweeping, because you've already got most of the tongue out of the way and supported by the blade.

After awhile it becomes second nature to more accurately judge the required depth, but when in doubt (as one tends to be when learning), err on the side of placing the blade too deep rather than too shallow. As long as you avoid excessive force when inserting the blade, the likelihood of vocal cord damage is minimal, because the width of the blade generally prohibits its advancement into the glottis.

I prefer the Miller blade these days. It is much easier to insert in narrow mouths and to advance farther after the initial insertion when necessary.

 

[leaverus]

Meh, there's no such thing as poor technique if it accomplishes the goal of getting the tube in the right place without causing any damage.

 

[proman]

I don't think burying the blade is a technique a novice should be using. It's fine to use as a last ditch if regular DL doesn't work but I think there's a higher risk of esophageal trauma and rupture with that technique. We're supposed to use laryngoscopy to identify airway structures. Burying the blade and hoping you see something isn't exactly what airway experts are supposed to do.

 

[BLADEMDA]

I've adopted the "burying the blade" technique for intubating where I put the blade in as much as possible at first and then come back till the epiglottis flops down. So far in my rotation, this has worked for me after one of my earlier attendings suggested it.

Yesterday, a new attending that I've never worked with scolded me for doing that because he said that it was poor form and may lead to unnecessary damage.

So I was curious... is this considered poor technique? Is the way where you advance slowly instead of backing up better?

I don't want to develop any bad habits... thanks for your input.

You need more intubations and aiway management. Have you considered doing video assisted intubations for practice/learning? It may help your understanding of anatomical locations. Of Course 300 more standard larygoscopies wouldn't hurt either.

 

[IlDestriero]

I think that more than a few members of the AANA would like to bury Blade.

 

[Bertelman]

I've adopted the "burying the blade" technique for intubating where I put the blade in as much as possible at first and then come back till the epiglottis flops down.

Don't know where you are in your training, but you should learn different techniques to getting a good view. Burying the blade can be a little forceful.

Consider the ENT room. Big tonsils, laryngeal masses, etc. Other day I had a mucocele excision. Bag the size of a small grape hanging in the back of his throat, basically blocking the light source on my blade, since it was on the left side of his pharynx. Ended up having to come from the left side of the mouth, sweep the grape out to the right, then advance the tube. Cases like that, burying the blade nets you a burst mucocele.

By the time you finish residency, you need to have several approaches to inserting and advancing the laryngoscope. Know when each is appropriate. Lateral approach if they have a large overbite, etc.

 

[WholeLottaGame7]

I think that more than a few members of the AANA would like to bury Blade.

I kinda thought that's where this thread was going to go, also...

 

[Soon2BENT]

I agree with the second attending in that you can cause unnecessary damage, but, I think the technique works well when using Miller blades. If the airway is a nice easy class 1 or class 2, I don't see the point "burying the blade".

just my advice.

 

[Laryngophed]

I think that more than a few members of the AANA would like to bury Blade.

I'm glad I wasn't the only person who thought about (and actually did!) post this.

 

[bigeyedfish]

I think this is a valid technique for beginners and people who are not experts in airways management. (ie people who are very unlikely to be tubing people with pharyngeal abscesses or masses.) I teach it to first timers with the caveat that its a beginner technique. Those who will go on to become experts will develop more sophisticated technique putting the blade in the mouth.

 

[Idiopathic]

Meh, there's no such thing as poor technique if it accomplishes the goal of getting the tube in the right place without causing any damage.

bolded for emphasis.

certainly a fair amount of risk of epiglottic trauma with this maneuver, especially with the curve of the Mac blade. the best plan would just be to find the valecula, where the blade is supposed to go, and then work towards getting your view. otherwise use a miller blade.