Miller Blade Advice

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propmidaz

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For Miller blade users out there, seeking tips and advice. Resident here and still learning but the docs here are not the best at teaching. One doc who uses the miller lets me struggle, is impatient, gets irritated and does not offer advice. Then he takes over intubates with the miller and then leaves the room with not a word and zero feedback and very unhelpful. Was fine with Peds using a Miller. Adults are more challenging and frustrating.

Have tried the paraglossal approach going in on the right, sweeping tongue, and then become "lost" and don't see cords. If I do see epiglottis, I can't get the blade underneath it to lift up. If I do not see epiglottis, its all tissue in there. Landmarks are not showing up. What is your best advice for starting out with the Miller?
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psychbender said:
When doing paraglossal, you may be going deep. Try slowly backing up, and/or use your free hand to push the cricoid back and to the right. It should drop right into view.
Click to expand...
You are probably right. Will try that the next time. On my intubation attempt today, went in on the on the right, advanced. saw nothing, tried to angle the blade to the left to see if there was any structures (epiglottis, etc.) and got no view of anything. Does angling the blade to the left make sense or am I just "going fishing" and searching in a black hole?
 
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propmidaz said:
You are probably right. Will try that the next time. On my intubation attempt today, went in on the on the right, advanced. saw nothing, tried to angle the blade to the left to see if there was any structures (epiglottis, etc.) and got no view of anything. Does angling the blade to the left make sense or am I just "going fishing" and searching in a black hole?
Click to expand...
You are probably being too timid as you should initially. There is def some gentle rocking you have to do at times and this is why it's higher risk for breaking teeth. If you anticipate someone to be a very easy airway maybe learn on them and stick to Mac till you figure it out and develope confidence. I was very poor with the Miller as a trainee and now I use it almost exclusively.
Also head lift and cricoid are very useful with the Miller.
 
propmidaz said:
You are probably right. Will try that the next time. On my intubation attempt today, went in on the on the right, advanced. saw nothing, tried to angle the blade to the left to see if there was any structures (epiglottis, etc.) and got no view of anything. Does angling the blade to the left make sense or am I just "going fishing" and searching in a black hole?
Click to expand...
Just angling left is mostly fishing in that situation. You'd need to back up a little, too, to get the tip into the right spot.
 
crash2500 said:
You are probably being too timid as you should initially. There is def some gentle rocking you have to do at times and this is why it's higher risk for breaking teeth. If you anticipate someone to be a very easy airway maybe learn on them and stick to Mac till you figure it out and develope confidence. I was very poor with the Miller as a trainee and now I use it almost exclusively.
Also head lift and cricoid are very useful with the Miller.
Click to expand...
Thanks, for the reply. Do you use the paraglossal approach or go in deep to the esophageal and then pull back?
 
propmidaz said:
Thanks, for the reply. Do you use the paraglossal approach or go in deep to the esophageal and then pull back?
Click to expand...
Learning on patients with no teeth is perfect. I use the Miller on everyone without top teeth just to keep the practice. But I more or less do the paraglossal approach AND intentionally drive a little deep, lift, then slowly pull back.
 
I use primarily miller, sometimes Mac. Get a sense of the airway by looking at the patient, after enough experience you’ll find which you prefer and nail down your style. Some of my friends swear by one or the other, the best one is the one that works for you.

I think millers are better for those large jaw, long thyromental distance patients where a mac just gives you a grade 4 view and hopefully the burp maneuver (backward, upward, rightward pressure; this is what people mean when they say cricoid, which is technically different, someone should show you how to do this well, it looks trivial but it can make a major difference in views. Before I dl I tell the circulator if I don’t know them that I want them to put their fingers in a specific location, mostly for ones who are distracted and think they’re just pressing). I’ve watched crnas who have had dental trauma incidents (not a judgment I just don’t watch other anesthesiologists), they crank way too much. The only wrist motion you should have is to pick up the epiglottis, think of a miller as an extension of your arm, it shouldn’t have to be angled to do any work, people often don’t apply enough upward pressure to the mandible when they’re DLing, watch ents do rigid dls, they sometimes have to lift the head up off the pillow.

Macs: I find them better for the small mouth openings and the super morbidly obese where excess tissue is the issue

Jay Leno: miller 3
Andre the giant: Mac 4
 
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ENT here and work with almost exclusively straight scopes just because that’s what we can instrument through. Whenever I don’t have my stuff and need a scope though I always ask for a miller, usually a 3 for most adults.

There’s definitely a learning curve for straight blades and I think the only way I got good was all of our DLs where we take a look after the patient is already intubated. Not only does the tube give the trainee a path to follow, but you get to take some time and learn the anatomy and relationships without the pressure of having to secure the airway. I don’t know if there’s ever time to take a look with a Miller after intubation but it might be a nice way to build some familiarity.

Little things that help me:

1) mouth guard over upper teeth. Gives a little margin for error, thought not that much.

2) position is key. Gotta have that sniffing position set up in advance. For me that usually means manually cocking the head piece of the bed 30-45degrees up before taking a look (or during if things look a wee bit anterior).

3) beware anything that will F with the angle you need. Mandibular tori are the bane of my existence. Not getting the tongue out the way will have a similar effect. If you eyeball the patient from the side you can see the thyroid cartilage, cords are about halfway down it, so just eyeball the angle you’ll ultimately need. This is how I know what a student or resident is seeing even though I can’t see directly through the scope while they are. In advance I adjust position so I have the easiest shot possible straight to the glottis.

4) make sure all the air is sucked out of the ETT balloon so it’s tight to shaft. A lot of tubes seem to have slightly inflated cuffs and sometimes these F with my view when looking down the barrel of a miller.

5) straight blades tend to be a two handed motion. My left is very gently holding the handle but my right usually rests on the upper dentition and I used my right thumb and forefinger to manipulate and advance the blade of the scope. It’s a gentle motion, neither rocking nor lifting. When I don’t have a mouth guard, I’ll rest my right index finger on the upper teeth to prevent chipping one, thumb on the back of the blade. Left hand gently lifts while thumb carefully advances.
 
propmidaz said:
For Miller blade users out there, seeking tips and advice. Resident here and still learning but the docs here are not the best at teaching. One doc who uses the miller lets me struggle, is impatient, gets irritated and does not offer advice. Then he takes over intubates with the miller and then leaves the room with not a word and zero feedback and very unhelpful. Was fine with Peds using a Miller. Adults are more challenging and frustrating.

Have tried the paraglossal approach going in on the right, sweeping tongue, and then become "lost" and don't see cords. If I do see epiglottis, I can't get the blade underneath it to lift up. If I do not see epiglottis, it’s all tissue in there. Landmarks are not showing up. What is your best advice for starting out with the Miller?
Click to expand...
I have this really useful maneuver… where I throw the Miller in the bin and use a MAC blade instead.
 
I preface my demonstration of using a Miller blade to medical students and novice residents with the statement that "This is a snow shovel and not a crowbar." If it were winter I would do a riff on The Karate kid." and make them shovel every step in a neighborhood. The biggest mistake is to either pry or do the "dip and dive" when the tongue gets under the blade. Get beside the tongue and maintain lift to the midline. One quick shoveling motion will get a great view in most patients. If you don't see the larynx or epiglottis you are likely too deep and a small amount of withdrawal while maintaining lift will bring it into view.
 
As a lowly CRNA who thinks the Miller is the blade of champions,(sorry like it so much more then MAC), paraglossal go deep and come back. In time you will not go to deep. My personal advice.
 
idk I work with lots of Srna’s and crnas in my current practice in Tx that use the miller and they bust the lips more often than the mac users. I’m hoping my new crnas use the mac… although I hear there’s a McGrath in every OR - which I’ve never used before but I’m sure it’ll be fine…. We have the glide and provu now and I love both.
 
Speaking of breaking teeth -

Everybody always talks about prying motion being the culprit and the biggest risk. I'm not so sure. Teeth are pretty tough, unless we're talking meth mouth or advanced decay. Obviously contact with the upper incisors should be avoided but it's not like they're made of glass. A little direct backwards pressure won't hurt them.

I think the real tooth-breaking risk with DL is the exaggerated tongue sweeping motion some people are teaching, in which the blade goes in sideways to push the tongue to the left, and then the handle is rotated upward to lift the tongue. That approach can get the thin edge of the blade between teeth, and the subsequent rotation has MASSIVE force which WILL break a tooth.

I don't know how many times I've had to stop trainees doing this, to explain that risk. Light bulb goes on, then they say "but I was taught to sweep the tongue..."



I have no general advice for the Miller, beyond "use a mac". 🙂
 
pgg said:
Speaking of breaking teeth -

Everybody always talks about prying motion being the culprit and the biggest risk. I'm not so sure. Teeth are pretty tough, unless we're talking meth mouth or advanced decay. Obviously contact with the upper incisors should be avoided but it's not like they're made of glass. A little direct backwards pressure won't hurt them.

I think the real tooth-breaking risk with DL is the exaggerated tongue sweeping motion some people are teaching, in which the blade goes in sideways to push the tongue to the left, and then the handle is rotated upward to lift the tongue. That approach can get the thin edge of the blade between teeth, and the subsequent rotation has MASSIVE force which WILL break a tooth.

I don't know how many times I've had to stop trainees doing this, to explain that risk. Light bulb goes on, then they say "but I was taught to sweep the tongue..."



I have no general advice for the Miller, beyond "use a mac". 🙂
Click to expand...
... how do you even get the flat side of the blade between the teeth? I could maybe understand that for people missing every other tooth or with an insane front gap (my youngest will DEFINITELY need braces to fix that), but it shouldn't really get between normal teeth.
 
Radetzky said:
I have this really useful maneuver… where I throw the Miller in the bin and use a MAC blade instead.
Click to expand...
Honestly what even is a miller blade?
Mac 3, if no go, glidescope, sit down for a few hours.
Its not hard
 
nimbus said:
Mac4 for sure.

Click to expand...
Lolz. Those are many steps.

I had an attending way back when I was a student, managed to convince me the right way was to DL right handed and intubate with my left. I pulled it off, somehow, vision was a bitch, and I couldn't figure out just why he was laughing.
 
To become proficient with the Miller blade I decided to use one during residency for every intubation for a month. Concentrated repetition is required to master a skill. Practice makes perfect.

Back in the dark ages when I was practicing I used a 3.5 IV Mac like this one: Sun-Med American IV Mac Improved Vision Conventional Illuminatio. The rounding of the blade allows approximately 30 degrees field of vision improvement over standard Mac blades.
 
nimbus said:
Long forgotten right-handed inverse grip DL followed by mouth to tube ventilation.
Click to expand...
If you ever have to reintubate someone prone it may be beneficial.
Its a variant of a reasonably obscure, pretty advanced technique called the tomahawk intubation
Im sure that's not what they were going for tho here
 
PpfSuxTube said:
If you ever have to reintubate someone prone it may be beneficial.
Its a variant of a reasonably obscure, pretty advanced technique called the tomahawk intubation
Im sure that's not what they were going for tho here
Click to expand...
Actually had to do that, once, coding someone in a tight bathroom. It was very weird, but worked.
 
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