Mac vs Miller

[BLADEMDA]

Did you see the Anesthesiology News article where they used the Miller blade routinely and obtained success 96 percent of the time?

In my practice the Miller blade is used 3 to 1 over the Mac blade for routine intubations.
We already knew that since your first attempt is supposed to be successful why not utilize the laryngoscope blade which does exactly that: Miller 2

I imagine most private practices with experienced people use the Miller blade routinely while academia utilizes Mac 3/4. Once I was in practice for about 12-18 months I switched to the Miller 2 for all my intubations and never looked back. Now, the only time I use the MAc blade is for teaching purposes, double lumen tube placement (edentulous) and when that's the only blade in the drawer.

As for sore throats being greater with Miller vs Mac that's operater dependent and we haven't seen it.

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[imfrankie]

Did you see the Anesthesiology News article where they used the Miller blade routinely and obtained success 96 percent of the time?

In my practice the Miller blade is used 3 to 1 over the Mac blade for routine intubations.
We already knew that since your first attempt is supposed to be successful why not utilize the laryngoscope blade which does exactly that: Miller 2

I imagine most private practices with experienced people use the Miller blade routinely while academia utilizes Mac 3/4. Once I was in practice for about 12-18 months I switched to the Miller 2 for all my intubations and never looked back. Now, the only time I use the MAc blade is for teaching purposes, double lumen tube placement (edentulous) and when that's the only blade in the drawer.

As for sore throats being greater with Miller vs Mac that's operater dependent and we haven't seen it.

During residency I had an attending who told me the same thing (he carried a Miller 3 in his back pocket); so I committed to the switch then and continue like you.

 

[rsgillmd]

Haven't seen the article. You only mention the success rate with the Miller blade. What did they say the success rate was with the Macintosh blade?

While I feel comfortable using both, unless I think they are likely to have a more cephalad larynx, I'll go with the Mac blade. I have a high rate of success with it in my hands.

Cross my fingers, I've only had one unexpected difficult intubation so far since residency. The Miller in that case did not help me. I ended up intubating using the Glidescope.

I still stick with the old adage of: use what you are most comfortable with.

As far as sore throat, I never noticed a difference either between Mac or Miller.

 

[Planktonmd]

The best blade is the one that feels good in your hands and you get the best results with.
It can a Miller, a MAC, a Wisconsin...
Whatever works for you...
This is similar to asking "what is the best hand gun?"
The answer is: the gun that feels right in your hand.

 

[BLADEMDA]

The best blade is the one that feels good in your hands and you get the best results with.
It can a Miller, a MAC, a Wisconsin...
Whatever works for you...
This is similar to asking "what is the best hand gun?"
The answer is: the gun that feels right in your hand.

I'm just commenting that my practice is 3:1 for the Miller like the Oschner guys. We like that blade. You get a better view more consistently with a Miller vs a Mac. I don't care which blade you use but I'm a Miller man for decades Now.

 

[soonerfrog]

We all know the Miller blade is an inferior piece of technology that only barbarians and philistines still use. The Miller blade shows us that people can and still choose to worker harder not smarter. The good Lord was wise enough to bless us with the bountiful goodness of the Macintosh blade, I see no reason to spite him. Ronald Miller himself once called the Miller blade, "...an instrument of the Devil, sent from the depths of hell for torture and derangement."

 

[pgg]

We all know the Miller blade is an inferior piece of technology that only barbarians and philistines still use. The Miller blade shows us that people can and still choose to worker harder not smarter. The good Lord was wise enough to bless us with the bountiful goodness of the Macintosh blade, I see no reason to spite him. Ronald Miller himself once called the Miller blade, "...an instrument of the Devil, sent from the depths of hell for torture and derangement."

In the true spirit of the SDN anesthesia forum, I think it is now appropriate to derail this into a gun thread. I'll start: 9mm is the suck compared to .45acp, and AKs are crappy pot-metal Soviet Bloc junk far inferior to the AR platform.

 

[BobBarker]

I use a Mac blade most of the time but occasionally when I use a miller I get attitude from certain attendings. "Oh, you are a straight blade man. I didn't know.." in the same tone as "Oh, you give BJs in the men's restroom at the park. I didn't know.." F'em.

 

[Ignatius J]

I use both. I struggle on certain airways with both. For Mac, anterior airways aren't indeal. For Miller, large tongues and small glottises aren't ideal. I think the best clinician can use both interchangeably and knows when to ditch them for another airway device.

 

[Planktonmd]

In the true spirit of the SDN anesthesia forum, I think it is now appropriate to derail this into a gun thread. I'll start: 9mm is the suck compared to .45acp, and AKs are crappy pot-metal Soviet Bloc junk far inferior to the AR platform.

I usually don't participate in the gun discussions but this one is worth it.
I disagree that 9mm is bad because with the right 9mm ammunition and 17 bullets in the magazine you have incredible stopping power at your finger tip.
That said, I recently got a Sig 1911 and absolutely love it!
I still keep a full magazine of good hollow point in my Glock 17 for my home defense, right next to my shotgun of course

 

[Planktonmd]

In the true spirit of the SDN anesthesia forum, I think it is now appropriate to derail this into a gun thread. I'll start: 9mm is the suck compared to .45acp, and AKs are crappy pot-metal Soviet Bloc junk far inferior to the AR platform.

And I love AKs

 

[BLADEMDA]

I use both. I struggle on certain airways with both. For Mac, anterior airways aren't indeal. For Miller, large tongues and small glottises aren't ideal. I think the best clinician can use both interchangeably and knows when to ditch them for another airway device.

Anyway doing this gig for a few decades can use a tongue blade to intubate. I'm a Miller man but I can use anything 99% of the time.

My hunch is the majority of private practice guys are Miller men but like anything there are Planktons out there.

 

[pgg]

I usually don't participate in the gun discussions but this one is worth it.
I disagree that 9mm is bad because with the right 9mm ammunition and 17 bullets in the magazine you have incredible stopping power at your finger tip.
That said, I recently got a Sig 1911 and absolutely love it!
I still keep a full magazine of good hollow point in my Glock 17 for my home defense, right next to my shotgun of course

I agree with you, just mocking the Mac/Miller debate. Nothing wrong with 9mm. Here in CA we have a magazine capacity law, so I prefer .45 ... I figure that as long as I'm limited to 10 rounds or less, they might as well be big ones.

Re: AKs ... I'll admit that any gun that has "pipe wrench" in its standard tool set has a certain charm to it.

 

[Yangkower]

Personally I've never seen anyone have success intubating with a Glock or 9mm. I've had a few patients try it themselves but they ended up with a very bloody airway.

Incidentally have any of you ever tried intubating without a blade. Elevating tongue and jaw with your left and index fingers then passing the tube?

 

[BLADEMDA]

We all know the Miller blade is an inferior piece of technology that only barbarians and philistines still use. The Miller blade shows us that people can and still choose to worker harder not smarter. The good Lord was wise enough to bless us with the bountiful goodness of the Macintosh blade, I see no reason to spite him. Ronald Miller himself once called the Miller blade, "...an instrument of the Devil, sent from the depths of hell for torture and derangement."

Mac is for amatuers. I'm a Miller man. Very few airways that can't be successfully intubated with a Miller 2/3. The Anesthesiology News article just confirms what I already knew as fact: Success more readily achieved with a Miller blade.

 

[Planktonmd]

Anyway doing this gig for a few decades can use a tongue blade to intubate. I'm a Miller man but I can use anything 99% of the time.

My hunch is the majority of private practice guys are Miller men but like anything there are Planktons out there.

True... there are planktons out there and there are people (like blade) who think that if you shoot 9 mm ammo you are screwed

 

[Planktonmd]

Here is the deal:
Miller = Jeep : a good transportation that can be used in all kinds of environments but it is bumpy, crappy technology, slow, and ******ed!
Mac = Cadillac : smooth, sophisticated, but can not be used as an ATV and rednecks hate it.

 

[BLADEMDA]

 

[BLADEMDA]

Miller Blade is like a Land Rover. It gets the job done in the CIty or the Country while giving you a nice, firm ride the entire time. You can count on it rain or shine.

Miller is the ALL TERRAIN BLADE of choice and the go to blade when things get rough.

 

[Planktonmd]

Miller Blade is like a Land Rover. It gets the job done in the CIty or the Country while giving you a nice, firm ride the entire time. You can count on it rain or shine.

Miller is the ALL TERRAIN BLADE of choice and the go to blade when things get rough.

All Land Rovers leak oil and are too stiff for a city life style... but most rednecks don't like city life

 

[BLADEMDA]

New Risk Index for Miller Blade Aids Adult Intubation

by Michael Vlessides
Chicago—Compared with the Macintosh blade, the Miller might seem like something of an understudy. After all, whereas several multivariate indices of airway risk factors exist to assist in the prediction of difficult laryngoscopy and orotracheal intubation with the Macintosh blade, the Miller has received far less attention.
But that might be changing. Researchers at Ochsner Medical Center, in New Orleans, have developed a multivariate risk index for Miller laryngoscopy in adult elective surgery patients.
Mallampati class, thyromental distance and ability to prognath were predictors for inferior Cormack-Lehane views; modified Mallampati class and head/neck extension predicted increased attempts at orotracheal intubation, the researchers said.
“The Miller-2 blade is used most often at our institution,” said William B. Landry, MD, staff anesthesiologist at Ochsner. “Our practitioners are highly skilled with it, so we thought our institution would be an appropriate place to conduct this study.”
Dr. Landry and his colleagues enrolled 978 patients over age 17 years, who were scheduled for elective surgery requiring orotracheal intubation for general anesthesia.
The researchers recorded every patient’s airway risk factors preoperatively, including modified Mallampati class, mouth opening, thyromental distance, neck extension, ability to prognath, previous history of difficult intubation, sex, weight and height.
“The anesthesia provider then recorded, during direct laryngoscopy, the Cormack-Lehane view, the number of attempts required to successfully intubate the patient, and if any subsequent or additional airway devices were needed to intubate the patient,” Dr. Landry said.
Intubation succeeded in 96.2% of the 978 patients with the Miller blade, with the remaining patients requiring alternate airway tools—including intubating catheters and video laryngoscopes—or three attempts at intubation.
Identifying risk factors for difficult intubation is a key task for the anesthesiologist, Dr. Landry said. “Inability to intubate and ventilate is probably the single most significant factor related to adverse respiratory events in general anesthesia,” he said. “A lot of times, as an anesthesiologist you can walk into an exam room, look at a patient from a distance and recognize physical characteristics right away. Some patients, though, are not that easy to identify and you do need some sort of algorithm or physical exam to determine who’s going to give you trouble.”
Robert S. Greenberg, MD, associate professor of anesthesiology and critical care medicine at The Johns Hopkins Hospital, in Baltimore, said the new study helps illustrate that even in medicine, the magician is sometimes more important than the wand.
But Dr. Greenberg noted that the Ochsner team likely has more experience using Miller blades than most anesthesiology groups, at least for adult patients. “I wonder how many other groups have such expertise and how generalizable these results are,” he added. “In fact, with the apparent pervasive use of ‘adjunctive devices’ like video laryngoscopy, I wonder if such expertise may be going the way of expert mask management, or even open-drop anesthesia.”

 

[Planktonmd]

Bull ****!
Is that politically correct?

New Risk Index for Miller Blade Aids Adult Intubation

by Michael Vlessides
Chicago—Compared with the Macintosh blade, the Miller might seem like something of an understudy. After all, whereas several multivariate indices of airway risk factors exist to assist in the prediction of difficult laryngoscopy and orotracheal intubation with the Macintosh blade, the Miller has received far less attention.
But that might be changing. Researchers at Ochsner Medical Center, in New Orleans, have developed a multivariate risk index for Miller laryngoscopy in adult elective surgery patients.
Mallampati class, thyromental distance and ability to prognath were predictors for inferior Cormack-Lehane views; modified Mallampati class and head/neck extension predicted increased attempts at orotracheal intubation, the researchers said.
“The Miller-2 blade is used most often at our institution,” said William B. Landry, MD, staff anesthesiologist at Ochsner. “Our practitioners are highly skilled with it, so we thought our institution would be an appropriate place to conduct this study.”
Dr. Landry and his colleagues enrolled 978 patients over age 17 years, who were scheduled for elective surgery requiring orotracheal intubation for general anesthesia.
The researchers recorded every patient’s airway risk factors preoperatively, including modified Mallampati class, mouth opening, thyromental distance, neck extension, ability to prognath, previous history of difficult intubation, sex, weight and height.
“The anesthesia provider then recorded, during direct laryngoscopy, the Cormack-Lehane view, the number of attempts required to successfully intubate the patient, and if any subsequent or additional airway devices were needed to intubate the patient,” Dr. Landry said.
Intubation succeeded in 96.2% of the 978 patients with the Miller blade, with the remaining patients requiring alternate airway tools—including intubating catheters and video laryngoscopes—or three attempts at intubation.
Identifying risk factors for difficult intubation is a key task for the anesthesiologist, Dr. Landry said. “Inability to intubate and ventilate is probably the single most significant factor related to adverse respiratory events in general anesthesia,” he said. “A lot of times, as an anesthesiologist you can walk into an exam room, look at a patient from a distance and recognize physical characteristics right away. Some patients, though, are not that easy to identify and you do need some sort of algorithm or physical exam to determine who’s going to give you trouble.”
Robert S. Greenberg, MD, associate professor of anesthesiology and critical care medicine at The Johns Hopkins Hospital, in Baltimore, said the new study helps illustrate that even in medicine, the magician is sometimes more important than the wand.
But Dr. Greenberg noted that the Ochsner team likely has more experience using Miller blades than most anesthesiology groups, at least for adult patients. “I wonder how many other groups have such expertise and how generalizable these results are,” he added. “In fact, with the apparent pervasive use of ‘adjunctive devices’ like video laryngoscopy, I wonder if such expertise may be going the way of expert mask management, or even open-drop anesthesia.”

 

[pgg]

Mac is for amatuers. I'm a Miller man. Very few airways that can't be successfully intubated with a Miller 2/3. The Anesthesiology News article just confirms what I already knew as fact: Success more readily achieved with a Miller blade.

So they did a study at a place where "the miller-2 blade is most often used" and found that it worked 96.2% of the time (yay, I guess, 19 out of 20 seems marginal to me).

They didn't have an arm of mac blades in the study, and if nearly everyone at the site has chosen the miller blade prior to the study, there'd be some performance bias there even if they did test mac blades.

And you're concluding that millers are better than macs on the strength of this silly self-congratulatory look-what-we-can-do "study"?


That's like taking 100 Marines with ARs, having them shoot 100 targets, hit 96 of them, and declaring that AKs suck. Which would be incidentally and accidentally true, but the study didn't prove that.

 

[BLADEMDA]

So they did a study at a place where "the miller-2 blade is most often used" and found that it worked 96.2% of the time (yay, I guess, 19 out of 20 seems marginal to me).

They didn't have an arm of mac blades in the study, and if nearly everyone at the site has chosen the miller blade prior to the study, there'd be some performance bias there even if they did test mac blades.

And you're concluding that millers are better than macs on the strength of this silly self-congratulatory look-what-we-can-do "study"?


That's like taking 100 Marines with ARs, having them shoot 100 targets, hit 96 of them, and declaring that AKs suck. Which would be incidentally and accidentally true, but the study didn't prove that.

Nope. My experience tells me Miller is better than Mac and the study confirms it.

 

[G0S2]

Nope. My experience tells me Miller is better than Mac and the study confirms it.

This "study" confirms that whether Mac or Miller, go with what you are most comfortable with or have used the most. I read this article the other day and thought it was silly.

 

[pgg]

Nope. My experience tells me Miller is better than Mac and the study confirms it.

The study quoted above doesn't mention a Mac blade at all.

How on earth can you possibly make the claim that the study "confirms" a Miller is superior to a Mac if the study didn't even look at Mac blades?

 

[MTGas2B]

I demand a Phillips blade for all of my intubations.

I'm a Mac guy. Does that make me bad. Agree study sucks. The only time I used straight blades routinely was when I had ready access to a phillips blade. Hate dealing with tongues. That being said the best blade is the one you're most comfortable with, I think. Straight curved or other.


On the iPhone

 

[PMPMD]

There was an old study by Henderson et al I believe that demonstrated better views with Miller blades using a paraglossal approach in the specific case of lingual tonsillar hypertrophy. Not exactly something that generalizes to all patients.

 

[PMPMD]

Here you go

Anaesthesia. 1997 Jun;52(6):552-60.

The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation.

Henderson JJ.

Source

Anaesthetic Department, Western Infumary, Glasgow, UK.

Abstract

In 10 cases of unexpected difficult tracheal intubation using the Macintosh laryngoscope blade, the larynx could not be seen. In each case, a good view was achieved using the Miller blade lateral to the tongue, which enabled tracheal intubation under direct vision. The results achieved using narrow, low-profile straight laryngoscope blades with this technique are reviewed. The improved view obtained with this technique is a consequence of reduced tongue compression as compared with the Macintosh technique. This leads both to an improved line of sight, and to a reduced risk of backward displacement of the tongue and epiglottis. In addition, the molar or retromolar variation of the technique reduces the intrusion of maxillary structures into the line of sight, so that a better view of the larynx is achieved for a given degree of soft tissue compression. Paraglossal straight blade laryngoscopy may have an advantage over use of the Macintosh technique when intubation proves unexpectedly difficult. It is perhaps time to question standard teaching about the role of the curved blade in such patients or, more particularly, whether the technique of laryngoscopy as currently taught is optimal. The paraglossal straight blade technique needs to be practised in routine intubation before it can be used with confidence in difficult cases.

 

[RussianJoo]

At my institution only CRNAs use Miller Blades consistently. I've had cases where I couldn't lift the epiglottis with the Mac, I switched to a Miller and got a grade 1 view, I can say the same for Millers and not being able to move the tongue out of the way..

 

[soonerfrog]

Blade's post is correct, just incomplete. "Miller blades are indeed the best __________". (...at scraping dog$hit off your boots).

 

[BLADEMDA]

At my institution only CRNAs use Miller Blades consistently. I've had cases where I couldn't lift the epiglottis with the Mac, I switched to a Miller and got a grade 1 view, I can say the same for Millers and not being able to move the tongue out of the way..

As you gain experience with the Miller blade moving the tongue out of the way becomes easier. Eventually, the tongue becomes a non issue with the Miler blade and you end up with better Grade 1 views more often than a Mac.

Do I care what blade someone uses provided they stay off the teeth and are successful intubating? No. I can tell you that the Miller provides more reliable and successful intubations on the first attempt.

 

[Planktonmd]

I can tell you that the Miller provides more reliable and successful intubations on the first attempt.

No it doesn't!

 

[BLADEMDA]

No it doesn't!

It is strange that you think the Mac is more successful at intubating ALL PATIENTS since the the Miller is the go to blade for anterior airways. Even if you prefer the Mac blade as your routine instrument for intubation the Miller blade offers advantages for anterior airways. The tongue issue is a non issue once you practice a great a deal with the Miller.

Logically, if you have a 1,000 patients over a year then at least a few will have anterior airways which the Miller will make intubating easier.

 

[BLADEMDA]

Blade's post is correct, just incomplete. "Miller blades are indeed the best __________". (...at scraping dog$hit off your boots).

BEST.... at rescuing you from failed intubation attempts with your Mac blade.

 

[Planktonmd]

It is strange that you think the Mac is more successful at intubating ALL PATIENTS since the the Miller is the go to blade for anterior airways. Even if you prefer the Mac blade as your routine instrument for intubation the Miller blade offers advantages for anterior airways. The tongue issue is a non issue once you practice a great a deal with the Miller.

Logically, if you have a 1,000 patients over a year then at least a few will have anterior airways which the Miller will make intubating easier.

It's all about perception!
The blade you use most tends to be the one you intubate better with.
If you are a beginner then you are likely to be more successful with a Miller since it does not require entering the mouth laterally, you can just go midline and achieve some kind of view.
You know what i do when a CRNA fails to intubate with a Miller?
I take a MAC 4 and put the tube in!
And that works about 90% of time.
The remaining 10% get FOB or Glidescope.

 

[Bertelman]

It's all about perception!
The blade you use most tends to be the one you intubate better with.
If you are a beginner then you are likely to be more successful with a Miller since it does not require entering the mouth laterally, you can just go midline and achieve some kind of view.
You know what i do when a CRNA fails to intubate with a Miller?
I take a MAC 4 and put the tube in!
And that works about 90% of time.
The remaining 10% get FOB or Glidescope.

Alternatively, you could probably take the same Miller blade and intubate anyways.

 

[BLADEMDA]

Alternatively, you could probably take the same Miller blade and intubate anyways.

Agreed. The skill of the practitioner matters more than the instrument he/she uses.

 

[thegasman]

crna with 20-30yrs experience looks with miller 2 "doc I can't see anything'. Me (attending with 4 yrs private practice) - mac 3 grade I-II view ett placed easily. Happens at least once a week. I am better with the mac. I like the miller, but I don't even need to see cords usually with the mac, I just know where they are in relation to the other anatomy (epiglottis etc.) The best blade depends on the operator and the patient. One is not better than the other all the time. The mac requires some strength to use so maybe the miller blade is better for weaklings. j/k

 

[BLADEMDA]

crna with 20-30yrs experience looks with miller 2 "doc I can't see anything'. Me (attending with 4 yrs private practice) - mac 3 grade I-II view ett placed easily. Happens at least once a week. I am better with the mac. I like the miller, but I don't even need to see cords usually with the mac, I just know where they are in relation to the other anatomy (epiglottis etc.) The best blade depends on the operator and the patient. One is not better than the other all the time. The mac requires some strength to use so maybe the miller blade is better for weaklings. j/k

The Best Physicians at intubating I have ever seen in my 2 plus decades at this have always used the Miller blade for difficult intubations. I have bailed out academic attendings as a Resident using the Miller blade. There is no comparison between a 4 wheel drive pickup and a VW bug when the road gets rough, sandy and full of big holes. This same analogy also applies to anterior airways with the Miller vs the Mac. FYI, the Miller blade requires significant strength for anterior airways which is why your CRNA fails frequently. IN addition, you must know your airway anatomy even MORE With a Miller blade because your view is compressed compared to a Mac blade.

In short, you need more skill and more practice with a Miller blade compared to a Mac blade to become an expert. This extra skill is why many prefer the "easy" Mac blade over the bad ass Miller blade where anterior airways are intubated with relative ease. Until you try the Miller blade for your next thousand cases how would really know which one is better for you? Having used both blades for thousands of intubations I firmly believe that the Miller 2/3 is the go to blade of choice.

 

[BLADEMDA]

Anaesth Intensive Care. 2008 Sep;36(5):717-21.
View of the larynx obtained using the Miller blade and paraglossal approach, compared to that with the Macintosh blade.

Achen B, Terblanche OC, Finucane BT.
Source

Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, Edmonton, Alberta, Canada.

Abstract

The purpose of this study was to determine if laryngoscopy using a Miller blade with a paraglossal approach would yield an improved view of the larynx compared to that obtained with a Macintosh blade using the standard approach. One-hundred and sixty-one patients, scheduled for elective surgery requiring tracheal intubation, voluntarily participated in this study. Patients were randomly assigned to one of the two groups (Miller vs. Macintosh). A standard general anaesthetic was administered. Comparisons were made of the percentage of the vocal cords visible at laryngoscopy. The view of the airway was also graded using the Cormack and Lehane scale. Statistical analysis using Fisher's exact test was performed. A P value < 0.05 was considered statistically significant. The time required to complete intubation and complications if any, were also recorded. Laryngoscopy using the Miller blade allowed 100% of the vocal cords to be viewed in 78% of cases, whereas this was achievable in only 53% with the Macintosh blade (P = 0.0014). The Miller blade enabled greater than 25% of the vocal cords to be seen in 95% of the cases, whereas this was achievable in only 80% with the Macintosh laryngoscope (P = 0.003). A grade 1 Cormack and Lehane view of the larynx was obtained in 96.5% of cases in the Miller group compared with 85% in the Macintosh group (P = 0.02). Direct laryngoscopy using the Miller blade and paraglossal approach, afforded a much-improved view of the larynx in the majority of cases. For this reason trainees should learn laryngoscopy using both blades.

 

[BLADEMDA]

Anaesthesia. 1997 Jun;52(6):552-60.
The use of paraglossal straight blade laryngoscopy in difficult tracheal intubation.

Henderson JJ.
Source

Anaesthetic Department, Western Infumary, Glasgow, UK.

Abstract

In 10 cases of unexpected difficult tracheal intubation using the Macintosh laryngoscope blade, the larynx could not be seen. In each case, a good view was achieved using the Miller blade lateral to the tongue, which enabled tracheal intubation under direct vision. The results achieved using narrow, low-profile straight laryngoscope blades with this technique are reviewed. The improved view obtained with this technique is a consequence of reduced tongue compression as compared with the Macintosh technique. This leads both to an improved line of sight, and to a reduced risk of backward displacement of the tongue and epiglottis. In addition, the molar or retromolar variation of the technique reduces the intrusion of maxillary structures into the line of sight, so that a better view of the larynx is achieved for a given degree of soft tissue compression. Paraglossal straight blade laryngoscopy may have an advantage over use of the Macintosh technique when intubation proves unexpectedly difficult. It is perhaps time to question standard teaching about the role of the curved blade in such patients or, more particularly, whether the technique of laryngoscopy as currently taught is optimal. The paraglossal straight blade technique needs to be practised in routine intubation before it can be used with confidence in difficult cases.

 

[BLADEMDA]

Masui. 1997 Nov;46(11):1519-24.
[Which laryngoscope is the most stressful in laryngoscopy; Macintosh, Miller, or McCoy?].

[Article in Japanese]
Nishiyama T, Higashizawa T, Bito H, Konishi A, Sakai T.
Source

Department of Anesthesiology, University of Tokyo Faculty of Medicine.

Abstract

Stress responses during laryngoscopy were compared among the situations using three different laryngoscopes, Macintosh (curved standard blade), Miller (straight blade), or McCoy (levering). Blood pressure, heart rate (in 58 patients) and plasma concentration of catecholamines (in 29 patients) were measured before, during and after laryngoscopy without tracheal intubation. Systolic blood pressure after laryngoscopy was significantly higher in the Miller group than in other two groups. Plasma epinephrine concentrations after laryngoscopy in the McCoy group were lower than other two groups. Heart rate and plasma norepinephrine concentration were not different among the three groups. These results suggest that the stress response during laryngoscopy without intubation is the biggest in using the Miller laryngoscope and the smallest in using the McCoy laryngoscope.

 

[BLADEMDA]

I know you guys have the Glidescope to bail you out. I also know you been taught the Mac blade is the better intubating blade. But, like a few others on SDN I define "better" by which blade can get the job done on the first attempt and with the highest rate of success; for me, that is clearly the Miller blade.

Still, I wonder just how many on this board have performed in excess of 1,000 intubations with a Miller blade? How about 2,000 intubations? Why not become extremely skilled with the Miller Blade along with your trusty Mac blade then make up your mind which is actually superior (for you in the majority of cases).

 

[BLADEMDA]

 

[BLADEMDA]

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04-14-2010, 07:31 PM #1jetproppilot
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Join Date: Mar 2005
Location: level at FL210
Posts: 5,449

Jetpearl Number 5
Don't believe the rhetoric that theres a "perfect blade" for different situations. There is not. The "perfect blade" is the blade that YOU can succesfully intubate with. Select a blade early in your career that will be your "go to" blade for a difficult intubation. Over time your skill with that blade will blossom. I am partial to the Miller 2. I can intubate a gravid fire ant with a Miller 2. Conversely, the chairman of my residencys "go to" blade was a Mac 3. I never saw him miss. He once intubated a prone persian cat with Da Mac. Goes to show what works for one clinician may not necessarily work for you. Don't let your attendings tell you otherwise.
__________________
Jet MD, LMFAO
Last edited by jetproppilot; 04-14-2010 at 08:38 PM.

​

 

[BLADEMDA]

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04-14-2010, 07:31 PM #1jetproppilot​

Turboprop Driver











Join Date: Mar 2005


Location: level at FL210


Posts: 5,449

Jetpearl Number 5


Don't believe the rhetoric that theres a "perfect blade" for different situations. There is not. The "perfect blade" is the blade that YOU can succesfully intubate with. Select a blade early in your career that will be your "go to" blade for a difficult intubation. Over time your skill with that blade will blossom. I am partial to the Miller 2. I can intubate a gravid fire ant with a Miller 2. Conversely, the chairman of my residencys "go to" blade was a Mac 3. I never saw him miss. He once intubated a prone persian cat with Da Mac. Goes to show what works for one clinician may not necessarily work for you. Don't let your attendings tell you otherwise.


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Jet MD, LMFAO


Last edited by jetproppilot; 04-14-2010 at 08:38 PM. ​

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While I agree with JPP about the MIller blade I disagree with him about being just a "mac" person. Why not become proficient with BOTH blades over your career? Sure, get good with the Mac blade but then why not get good with the Miller as well? In a busy practice the daily opportunity for intubations are numerous.

Oh well, the Glidescope is here so perhaps this discussion is moot.

 

[periopdoc]

Bah, I just close my eyes, reach into the blade drawer and intubate with whatever comes out as long as it is of a reasonable length. 6 of one 1/2 dozen of the other.

- pod

 

[soonerfrog]

Best Blade (laryngoscope) story: Attending about to intubate, asks resident for blade. Resident asks him which blade he wants, attending says, "I don't care, hand me any blade, I can tube this guy with whatever blade you hand me!". Resident hands attending a tongue blade. Moment of silence ensues followed by successful endotracheal intubation x1 attempt. Attending 1: resident: 0.

 

[Bertelman]

Best Blade (laryngoscope) story: Attending about to intubate, asks resident for blade. Resident asks him which blade he wants, attending says, "I don't care, hand me any blade, I can tube this guy with whatever blade you hand me!". Resident hands attending a tongue blade. Moment of silence ensues followed by successful endotracheal intubation x1 attempt. Attending 1: resident: 0.

That should be attending 2, resident 0. He already lost by letting the attending intubate.