CambieMD

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I have tried the Miller and Macintosh. I prefer the Mac. I was told that the Miller can rescue a difficult intubation but the same is not true of the Mac. Also I was told that you just about never neeed a Mac4 . I woud appreciate the opinion of any of anyone with some experience DVL.


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OldManDave

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CambieMD said:
I have tried the Miller and Macintosh. I prefer the Mac. I was told that the Miller can rescue a difficult intubation but the same is not true of the Mac. Also I was told that you just about never neeed a Mac4 . I woud appreciate the opinion of any of anyone with some experience DVL.


CambieMD

As a mere CA-2, my advice is to use what works best & is most comfortable in YOUR hands & not worry about what other folks tell you is best. What you are best with is not necessarily the same thing that is best in someone else's hands.

Furthermore, I am a strong STRONG believer in knowing as many different ways to skin the cats as is feasible. So, even though I am best/most comfortable with a MAC (I use which ever one seems to be the right size for my pt, incl 4s), I tend to use the Miller 2 or 3, again dependent upon pt anatomy, for my bail out blade & I will preferentially use the Miller to urgently/emergently intubate folks in c-collars. Time permitting, I will do awake/asleep FOI. Also, I frequently designate days as "No MAC" or "No DL" days & only use alternate airway devices. I cannot imagine many things more disturbing to have exhausted my bag of tricks after only having tried a MAc & then a Miller...I am a big fan of the Bougie for all emergency airway calls.
 

Skrubz

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like Dave, i feel most comfortable with a MAC. i usually use a 3, but have used a 4 on several occasions on really big (long of neck) patients. also like Dave, there are days when either i or my attending suggest just using the miller (or alternate means) to get more practice. just last week i had a miller day, an asleep fiberoptic day and a lightwand day.

of course, for a resident, especially a first year, it can be very attending dependent and usually it's the younger attendings that are more open to letting you experiment with different approaches.

the bougie is your friend and can save you when you can see the cords (and sometimes when you can't) but just can't get the bloody tube to go through. and no, dave hasn't paid me to say this. :D
 
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Laryngospasm

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Mac 3, Miller 2, Intubating LMA, bougie, blind nasal (rare). Usually in that order. If no workie, hope you can mask and either wake up and do FOI or do fiber optic asleep( which can be hard).
 

UTSouthwestern

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Miller every day. If I can't get an airway with the Miller, I know it's time to go hardcore (bougie, FOI, lightwand, etc.). I know at one rotation, the private practice group referred to the MAC as the ****y blade and that I wouldn't be allowed to use it the entire month. That made it easy for me.
 

thegasman

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I like the Mac for most airways, the tongue control is so nice with it, we have MAC 3.5 which is good for almost any adults. Occasionally there is an airway where you are in good position and regardless of the force you use ( MAC is a strength blade) you can't get the epiglottis to pick up. I've found the Miller works great for these, just grab it and lift. There is almost no tongue control with the miller though so the window you are looking through to the cords can be smaller. I agree that being very comfortable with both is important.
 

UTSouthwestern

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thegasman said:
I like the Mac for most airways, the tongue control is so nice with it, we have MAC 3.5 which is good for almost any adults. Occasionally there is an airway where you are in good position and regardless of the force you use ( MAC is a strength blade) you can't get the epiglottis to pick up. I've found the Miller works great for these, just grab it and lift. There is almost no tongue control with the miller though so the window you are looking through to the cords can be smaller. I agree that being very comfortable with both is important.
Try the Phillips blade if you want a broader straight blade for better tongue control.

Also try the Heine blade on those C collared patients. That's a fun blade to have available.
 

jwk

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Here's my old joke about blade selection...

Anyone can muscle a tube in with a straight blade. It takes skill and finesse to use a curved blade.

My sequence is Mac 3, Mac 3 + styletted tube with a wicked hockey stick curve at the end (if I didn't already have a stylet in), then light wand, then either wakeup (if I used sux) or LMA. I use a Miller about 3 times a year, usually in a room someone else had set up, and then just to use it and say I can. I never ever start with a Miller for anything. Others will obviously disagree. :laugh:

Far too many airways get messed up by repeated attempts at laryngoscopy. The days are long gone when you should have 5 people getting three tries each. Two looks, MAYBE a third if things look really promising, and THAT'S IT.

As others have stated - make sure you can use EVERYTHING, and get REALLY GOOD with your blade of preference, and (once you leave training of course) screw those who think their way is the best. Just like taping the tube - does it really matter how you do it as long as the friggin' tube doesn't come out?

And to paraphrase that famous saying...

Mac's rule, Millers drool.

Has anyone figured out I like Mac blades? ;)
 

adleyinga

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jwk said:
Here's my old joke about blade selection...

Anyone can muscle a tube in with a straight blade. It takes skill and finesse to use a curved blade.

My sequence is Mac 3, Mac 3 + styletted tube with a wicked hockey stick curve at the end (if I didn't already have a stylet in), then light wand, then either wakeup (if I used sux) or LMA. I use a Miller about 3 times a year, usually in a room someone else had set up, and then just to use it and say I can. I never ever start with a Miller for anything. Others will obviously disagree. :laugh:

Far too many airways get messed up by repeated attempts at laryngoscopy. The days are long gone when you should have 5 people getting three tries each. Two looks, MAYBE a third if things look really promising, and THAT'S IT.

As others have stated - make sure you can use EVERYTHING, and get REALLY GOOD with your blade of preference, and (once you leave training of course) screw those who think their way is the best. Just like taping the tube - does it really matter how you do it as long as the friggin' tube doesn't come out?

And to paraphrase that famous saying...

Mac's rule, Millers drool.

Has anyone figured out I like Mac blades? ;)

After 15 years of swearing by the MAC I was shown up by a CRNA using a Miller. I then swore to learn how to use it which I have. I start with a MAC and switch to a Miller if I have trouble. It has saved me and so has a bougie. Oh- MAC have worked when Miller hasn't at other times. ( that was when I showed up that same CRNA)

I have learned that both have uses
 

Noyac

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adleyinga said:
After 15 years of swearing by the MAC I was shown up by a CRNA using a Miller. I then swore to learn how to use it which I have. I start with a MAC and switch to a Miller if I have trouble. It has saved me and so has a bougie. Oh- MAC have worked when Miller hasn't at other times. ( that was when I showed up that same CRNA)

I have learned that both have uses
Ditto.
I start with the MAC and prefer the MAC (MAC4). But If I have trouble with it I go to the Miller.
 

VolatileAgent

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as soon as you're back in the OR (for most of us tomorrow morning), take a MAC 3 and a MAC 4 blade and hold them side-by-side. you'll be suprised to see that the "business end" is identical, it's just that the 4 is about 1.5 cm longer. the only time you ever need to use a MAC 3 (versus a 4) is if you have a really large patient with a huge upper chest mass (i.e. breasts) or a really short neck and you can't easily (or safely) maneuver the blade into the oropharynx. but, you can always use the "stubby" laryngoscope handle too. i find here in central PA that there's too many huge folks to routinely use the miller (harder to maneuver in, poor tongue control as was mentioned). still, no matter what you choose, it's all about proper positioning. if you got that, you can pretty much get any airway on the first shot no matter what you use... pretty much.
 

UTSouthwestern

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Try intubating a couple of Dallas Cowboys players, a high school basketball player who is 6'8, 240 lbs, and a former Dallas Mavericks player with a MAC 3. Ain't happening. MAC 4 was barely sufficient in length and I almost asked for the mythical MAC 5.
 

zippy2u

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The miller blade reminds me as being a farming implement like a plow that you'd run behind a horse or something. We're in the industrial age now in America and have been for some time; get your game together and transition yourself to becoming a mac-daddy. Regards ------Zip
 

jetproppilot

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UTSouthwestern said:
Miller every day. If I can't get an airway with the Miller, I know it's time to go hardcore (bougie, FOI, lightwand, etc.). I know at one rotation, the private practice group referred to the MAC as the ****y blade and that I wouldn't be allowed to use it the entire month. That made it easy for me.
I concur. But like someone said above, you can get great with any blade...

my chairman from residency, british dude, could intubate any adult with a Mac 3....well at least I never saw him miss, and he was always the one that the staff called after everybody missed.

But like UT, I like the Miller 2.
 

jetproppilot

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zippy2u said:
The miller blade reminds me as being a farming implement like a plow that you'd run behind a horse or something. We're in the industrial age now in America and have been for some time; get your game together and transition yourself to becoming a mac-daddy. Regards ------Zip
Ole Zipster cracks me up again.
 

militarymd

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I've had airways which I could not get with a miller and had to go mac and vice versa, so I personally just grab whatever is clean.

Jet....nice avatar!!
 

jetproppilot

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militarymd said:
I've had airways which I could not get with a miller and had to go mac and vice versa, so I personally just grab whatever is clean.

Jet....nice avatar!!
Thanks bro. Thats a Lockheed Constellation, affectionately known as the "Connie". My dad flew them back in the 50s for TWA. Beautiful bird.
 

Tenesma

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Miller 3 baby...

1) it's big and scary
2) what do ENTs and thoracic surgeons use for difficult airways? a rigid bronch... a miller 3 is pretty darn close
 
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