Is sweeping the tongue really necessary for MAC DL?

[europeman]

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Hello,

I'm a non-anestthesiologist in ICU fellowship currently on my airway rotation. I have noticed that most people teach to sweet the tongue to the left for a DL using a mac.

Is there anyone who doesn't do this? If so, why?

 

[TIVA]

If you fail to sweep the tongue to the left while performing direct laryngoscopy, whether it's with a mac blade or a miller, you will inevitably make an easy airway hard, and a difficult airway impossible.

 

[Idiopathic]

it isnt necessary until it is, but then it definitely is.

 

[dotcb]

The Mac blade is designed to be used this way. If you go in the midline (as in glidescope), the tongue will hang down over both sides of your blade - giving you about 1cm of total space to view the airway. It's like trying to look through a keyhole. If you start on the right and sweep, there should be minimal tissue hanging down on the right side of the blade, giving you much more room to visualize the airway.

One tip is that the end/tip of the laryngoscope needs to be in the midline (ideally buried in the vallecula), with the proximal end (by the handle) beginning on the right of the mouth. After you sweep, the entire blade should be in the midline. I've seen failure when the tip is not in the midline of the larynx. If you can't see familiar landmarks after your tongue sweep, try sweeping the tip a bit side to side. Remember - eventually everything needs to end up midline.

 

[Bostonredsox]

The Mac blade is designed to be used this way. If you go in the midline (as in glidescope), the tongue will hang down over both sides of your blade - giving you about 1cm of total space to view the airway. It's like trying to look through a keyhole. If you start on the right and sweep, there should be minimal tissue hanging down on the right side of the blade, giving you much more room to visualize the airway.

One tip is that the end/tip of the laryngoscope needs to be in the midline (ideally buried in the vallecula), with the proximal end (by the handle) beginning on the right of the mouth. After you sweep, the entire blade should be in the midline. I've seen failure when the tip is not in the midline of the larynx. If you can't see familiar landmarks after your tongue sweep, try sweeping the tip a bit side to side. Remember - eventually everything needs to end up midline.

my take as well. I have always used MACs. detest miller blades. I never really thought of it in the way you have described it here, but I do what you describe anyway because it just feels natural. Entering and then sweeping the tongue up and out just seems like the natural way to use a MAC.

 

[dhb]

I don't think it's absolutely necessary many times i don't really bother and stick the mac medial of course some time yu get a huge flap of tongue so i need to swipe a bit bhut overall i'm not an extreme swipper

 

[BlackTalon]

hmm, I am wondering why NOT sweep the tongue? Takes just a sec and there isn't any downside that I can think of and a whole lot of upside.

 

[europeman]

That's sorta the reason I posed the question. As a relatively new clinician to DL (i'm at about ~100 supervised tubes now), I have personally found that finding the epiglotis more straight forward without purposely sweeping the tonuge (literally). Not all the time.... but sometimes.

I never put the blade down straight in the middle of the tongue.... always slightly to the right of midline. I'm just saying that sometimes, and again maybe because I am notice, that sometimes when I make an effort to sweep the tongue I find that the epiglottis/larynx are approached off angle and I have sometimes confused the aryepiglottioc fold as the epiglottis edge.

Perhaps when I make an effort to sweep, i'm just doing it in too much of an exaggerated fashion thereby confusing my landmarks (as described above).

thoughts?

 

[dhb]

thoughts?

I feel ya

 

[IlDestriero]

You don't necessarily have to sweep the tongue with the Mac because of the flange, but you do have to control it. Just go in on the right side of the tongue and head to the middle. The tongue will shift left and be out of the way of the tube.
I'm more of a Miller man myself. Give me a Miller 1 and a miller 2 and I can intubate anybody, preemie to adults, excluding pro basketball players.😉

 

[btbam]

Pretty sure you could intubate a horse with a Miller 4.

 

[VentdependenT]

What the hell do we need a flange for anyways. Its not like blades are made out of weak metal these days. I bought a flange-less FO Mac 3 but havent used it yet. Will let ya know when I do.

 

[Spinach Dip]

Pretty sure you could intubate a horse with a Miller 4.

Well, I can add something useful to a conversation on this subforum for once, so here we go:

Nope.

A Miller 4 is not even long enough to reach a pig's vallecula. If you use it to sweep the tongue and stick it in the very corner of the pig's mouth, it is just possible to see the vocal cords and pass a bougie. At one point, the veterinarian was able to get a custom-made "Miller 5" which made the process tons easier, but it ended up breaking and getting stuck in a pig's esophagus. So it was back to the Miller 4.



And before you ask, YES, this was done under the observation of a veterinarian.

 

[VentdependenT]

Well, I can add something useful to a conversation on this subforum for once, so here we go:

Nope.

A Miller 4 is not even long enough to reach a pig's vallecula. If you use it to sweep the tongue and stick it in the very corner of the pig's mouth, it is just possible to see the vocal cords and pass a bougie. At one point, the veterinarian was able to get a custom-made "Miller 5" which made the process tons easier, but it ended up breaking and getting stuck in a pig's esophagus. So it was back to the Miller 4.



And before you ask, YES, this was done under the observation of a veterinarian.

I intubate my pigs using my fingers. "I feel pig cords."

 

[Spinach Dip]

I intubate my pigs using my fingers. "I feel pig cords."

Damn. Those are some long fingers.

 

[IlDestriero]

A long time ago made a pledge not to finger any pigs. Its served me well.