Mac or miller blade?

[tartesos]

In the end it's a matter of preference...
The technique is different enough to be confusing when learning( Mac in front of vallecula, miller lift the Glotis to reveal cords. )
Do any of you use both? I know some anes guys prefer miller, and swear it's better for some anterior airways.
In the end I just use miller and I'm pretty good at it, then is glide/ then scope( hopefully not!)

What do you guys think?

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[sluggs]

In the end it's a matter of preference...
The technique is different enough to be confusing when learning( Mac in front of vallecula, miller lift the Glotis to reveal cords. )
Do any of you use both? I know some anes guys prefer miller, and swear it's better for some anterior airways.
In the end I just use miller and I'm pretty good at it, then is glide/ then scope( hopefully not!)

What do you guys think?

I almost always use a mac 4; that said I have had 3 airways that I can recall having a terrible/no view with a Mac, and getting a better look with a miller

 

[Doctor Bob]

I use a mac4 primarily.
I can pull a mac4 back if it's in too deep, but I can't push a mac3 in any deeper than its full length.
I can also use a mac to lift up the epiglottis if necessary, but it's tough to use a miller in the vallecula.

But yea, there are times I pick up the Miller instead.

 

[subtle1epiphany]

Similar to the last two posts, Mac4 tends to work very well as it has similar height to the Mac3 and not all of the length is needed but there if needed.
That said, I have heard arguments for the Mac3 based on force application and distribution being more optimal. Miller tends to, IMHO, necessitate greater technique. While the blade may be helpful in some airways, I've had issues as a Fellow whereas it seemed easy to use as a Medical Student.
Not sure there is a clear better or worse, but as far as Video Laryngoscopes go, the CMAC is so wonderful when compared to the Glidescope.
Those are my thoughts.

 

[deleted171991]

In the end it's a matter of preference...
The technique is different enough to be confusing when learning( Mac in front of vallecula, miller lift the Glotis to reveal cords. )
Do any of you use both? I know some anes guys prefer miller, and swear it's better for some anterior airways.
In the end I just use miller and I'm pretty good at it, then is glide/ then scope( hopefully not!)

What do you guys think?

Videolaryngoscope. 😉

 

[Hernandez]

Mac 3.5

 

[jdh71]

Videolaryngoscope. 😉

This is what I use and I don't give an eff.

 

[CardiacIntensivist]

I usually go for 3 blades first in emergencies. If someone has a large thyromental distance or a long neck or is just a tall person, I will go for the MAC4. Why not just start with the MAC4? Because if the blade is too large, you may have to pull back too much and then you lose grip with the blade on the airway. A MAC blade that doesn't seat well tends to slide quite a bit.

I almost never use a miller during emergent intubations outside the ORs. Why? because non OR personal just do not know what I need. The Miller blade is great at lifting the epligottis but it SUCKS at getting that tongue out of the way or giving you enough room in the airway to get that tube past the teeth easily. OR nurses typically know how to hold the lips back for me if needed, non OR personnel do not.

I NEVER allow a newbie intubater to use the miller blade. I've seen too many crank that scope back and hammer down the teeth. The risk is even higher with the straight blade.

 

[Kahreek]

i learned with the curved one with the mannequin. Pretty sure i could become boss with either.

 

[Kahreek]

after long years of medical practice and training

 

[Bostonredsox]

I use a McGrath Mac video laryngoscope with a 3 or 4 blade. Doesn't really matter because I get this really pretty picture on my screen which is always a a grade 1 or 2 view

 

[austintr]

I started off with a strong preference for a Miller 2, but ended up using the Mac 3 quite a bit more...mainly because now if I'm not having good luck with the Mac, I can say, "It's Miller time!"

 

[jdh71]

*cues the rimshot*

Badum-splissssssssssh!

 

[mochief2000]

i started off with the Mac4 because older doctors :cough cough ER doctors: told me thats how bosses do it and an glidescope should be my backup. Truth be told I just use the glidescope on everybody because 1. I don't really listen to older doctors anyway 2. it's easier. My backup is anesthesiology. That's the good thing about CC, you USUALLY have time to assess if this person will be a difficult intubation and call the right people if the pt starts to go downhill......usually

 

[austintr]

Agree with the Glidescope...video laryngoscopy is the wave of the future...embrace it! But if you have to use a traditional blade, the Mac does have a shallower learning curve in my experience, due to better tongue control and ergonomics. But people who use Millers all the time usually achieve the same level of proficiency. The few times I've used a Grandview, I really liked it...Wisconsin blades, not so much. I'd say it all comes down to feel, familiarity and preference.

 

[CMS1]

In the end it's a matter of preference...
The technique is different enough to be confusing when learning( Mac in front of vallecula, miller lift the Glotis to reveal cords. )
Do any of you use both? I know some anes guys prefer miller, and swear it's better for some anterior airways.
In the end I just use miller and I'm pretty good at it, then is glide/ then scope( hopefully not!)

What do you guys think?

I call anesthesia for intubations, they are much, much better at it than I am. If I am in the ICU and need to be intubated I would rather have an anesthesiologist do it.

 

[tartesos]

I call anesthesia for intubations, they are much, much better at it than I am. If I am in the ICU and need to be intubated I would rather have an anesthesiologist do it.

Speaking for yourself of course.
If you would do more you wouldn't call anesthesia about 80-90% of the time.

 

[Laryngophed]

I try to take the approach of one my more senior attendings. I'm neither a Mac nor a Miller person. I use the blade that I think will provide the best exposure of the vocal cords for the patient. Sometimes that is a Mac 3; sometimes it is a Miller 3. Sometimes it is a videolaryngoscope and sometimes it is a fiberoptic bronchoscope.

I primarily use the Mac 3 now, not because I like it better but because I needed to learn with something and my options were essentially Mac 3 or Miller 2. So I picked the Mac 3. In a few months, I'll start defaulting to the Miller 2 (unless I work with one particular attending who HATES straight blades) and learn how to use it.

 

[gro2001]

I call anesthesia for intubations, they are much, much better at it than I am. If I am in the ICU and need to be intubated I would rather have an anesthesiologist do it.

I think it really depends on what your practice environment is like. At many academic places "calling anesthesia" gets you a PGY2 (or if you are very luck, PGY3) Anesthesia resident who may or may not be credentialed to use paralytics without his attending supervising. If you are comparing that to a PGY2 or PGY3 IM or EM resident, maybe they are going to be better. If you are comparing it to a seasoned ICU or EM attending, then it's going to vary based on the situation. If I needed to be intubated, of course I would prefer the battle hardened Anesthesia attending over the 1st year CC fellow or something like that. But usually that's not the choice you have. PGY3 Anesthesia resident vs ICU attending... hard to say.

 

[Icefrog]

I am anesthesia-trained and prefer the Miller. That being said, if you aren't an anesthesiologist and aren't facile with intubations, why not just use the Glidescope for everything if you have it? The airway is the airway and it's the primary concern in a critical situation.

I also feel like eventually video laryngoscopy is the wave of the future but the ego in me wants to take a crack at DL before resorting to VL. I guess it's a little cheaper too if they don't have to clean the glidescope, but by own mantra, if it looks like it could be difficult, I'm just gonna have the glidescope available even if I want to take first crack with DL because the airway seriously is nothing to screw around with.

 

[deleted547339]

I am anesthesia-trained and prefer the Miller. That being said, if you aren't an anesthesiologist and aren't facile with intubations, why not just use the Glidescope for everything if you have it? The airway is the airway and it's the primary concern in a critical situation.

I also feel like eventually video laryngoscopy is the wave of the future but the ego in me wants to take a crack at DL before resorting to VL. I guess it's a little cheaper too if they don't have to clean the glidescope, but by own mantra, if it looks like it could be difficult, I'm just gonna have the glidescope available even if I want to take first crack with DL because the airway seriously is nothing to screw around with.

Yea, but the VL scope failing or not having the right sized blade SUCKS.....

 

[jdh71]

I am anesthesia-trained and prefer the Miller. That being said, if you aren't an anesthesiologist and aren't facile with intubations, why not just use the Glidescope for everything if you have it? The airway is the airway and it's the primary concern in a critical situation.

I also feel like eventually video laryngoscopy is the wave of the future but the ego in me wants to take a crack at DL before resorting to VL. I guess it's a little cheaper too if they don't have to clean the glidescope, but by own mantra, if it looks like it could be difficult, I'm just gonna have the glidescope available even if I want to take first crack with DL because the airway seriously is nothing to screw around with.

I glidescope everything now because there is simply no reason not too.

 

[Doctor4Life1769]

I glidescope everything now because there is simply no reason not too.

I feel much better when I see RT using VL (they intubate at my new shop) until I see notice a few of them not knowing how to use it. Otherwise, I'm cool with it and have used it plenty of times.

 

[B-Bone]

I glidescope everything now because there is simply no reason not too.

glidescope failure (power, etc), bloody airway obscuring optics, tumor, jaw wired shut, limited mouth opening, etc. glidescope definitely not effective 100% of the time.

 

[jdh71]

glidescope failure (power, etc), bloody airway obscuring optics, tumor, jaw wired shut, limited mouth opening, etc. glidescope definitely not effective 100% of the time.

Oh really? That stuff actually happens? Huh. Who would have thought . . . Lol. Duh.

Still not a reason to use the glidescope on every case for me. If I think it's such a bad disaster then I'll have my anesthesia friends deal with it. That's just the nature of the beast.

 

[Hamhock]

I think each provider must decide if she will become the master of the emergent airway or not.

If you so choose, then you must master DL and all adjuncts. VL is a nothing more than an adjunct.

I have found more airways that could not be secured with VL than DL. Of course, more than 95% can be secured with both and there is a very small percent than can be secured with neither DL nor VL.

If I was in training again now -- and not in EM or anesthesiology -- I would focus on VL, good BVM, LMA, and cric.

I can't offer an informed opinion regarding anesthesiology training, but if I was training in EM again, I would learn VL but realize DL is my back up (yes, this is opposite of what is usually taught) and DL is my go to. EM docs must be masters of the emergent airway (which is very distinct from the OR elective airway). I would focus on the bougie, iLMA, and cric as well.

Of course, I think the modern EM doc should also be familiar with awake bronchoscopic intubation as well...but that is for a different thread.

HH

 

[deleted547339]

I think each provider must decide if she will become the master of the emergent airway or not.

If you so choose, then you must master DL and all adjuncts. VL is a nothing more than an adjunct.

I have found more airways that could not be secured with VL than DL. Of course, more than 95% can be secured with both and there is a very small percent than can be secured with neither DL nor VL.

If I was in training again now -- and not in EM or anesthesiology -- I would focus on VL, good BVM, LMA, and cric.

I can't offer an informed opinion regarding anesthesiology training, but if I was training in EM again, I would learn VL but realize DL is my back up (yes, this is opposite of what is usually taught) and DL is my go to. EM docs must be masters of the emergent airway (which is very distinct from the OR elective airway). I would focus on the bougie, iLMA, and cric as well.

Of course, I think the modern EM doc should also be familiar with awake bronchoscopic intubation as well...but that is for a different thread.

HH

Boo. Hiss.

 

[Random Anesthesiologist]

Oh really? That stuff actually happens? Huh. Who would have thought . . . Lol. Duh.

Still not a reason to use the glidescope on every case for me. If I think it's such a bad disaster then I'll have my anesthesia friends deal with it. That's just the nature of the beast.

What if the anesthesiologist isn't in house?

 

[jdh71]

What if the anesthesiologist isn't in house?

Then you gotta do what ya gotta do doncha?

 

[DrDrummer]

I feel much better when I see RT using VL (they intubate at my new shop) until I see notice a few of them not knowing how to use it. Otherwise, I'm cool with it and have used it plenty of times.

Is this pretty common? Never heard of RT doing the intubations routinely.

 

[Doctor4Life1769]

Is this pretty common? Never heard of RT doing the intubations routinely.

It happens in community hospitals.

If RT needs to sedate or paralyze a patient (or if it's a difficult airway), then anesthesia gets involved to intubate.

 

[deleted547339]

Is this pretty common? Never heard of RT doing the intubations routinely.

I know of a few hospitals where this happens in my area.

 

[Mad Jack]

Is this pretty common? Never heard of RT doing the intubations routinely.

Lot of places around here where RTs intubate. One hospital they work on the flight ambulance service and do all of the intubations in the ER when they aren't flying. In a few of the others, they do all of the intubations, unless there are predicted complications.

 

[Doctor Bob]

Is this pretty common? Never heard of RT doing the intubations routinely.

Theoretically, anyone who has taken ACLS is "trained" to intubate. So it's up to the hospitals to decide who they want to credential to do it.
Nurses, techs..., <shrug> send the janitor to ACLS and then they could do it too...

 

[europeman]

I like Mac 3 Usually. Better torque. It's just physics.

 

[Random Anesthesiologist]

Then you gotta do what ya gotta do doncha?

You know it.

 

[Random Anesthesiologist]

Theoretically, anyone who has taken ACLS is "trained" to intubate. So it's up to the hospitals to decide who they want to credential to do it.
Nurses, techs..., <shrug> send the janitor to ACLS and then they could do it too...

Agree. It's a matter of risk in the end and what risk is the credentialed responder willing to assume in a logical scenario.