Miller blade technique?

[26B]

It seems that the attendings at my institution fall into 2 camps when it comes to using the Miller blade. A majority (probably over 80%) recommend going in straight down over the midline of the tongue, while a few swear by the right paraglossal approach, where the blade is inserted into the gutter between the tongue and tonsil.

Which technique do you prefer when using the Miller blade, and why?

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[Psai]

I'm no JPP but from reading old posts on here, people say if you go paraglossal, you skip past the epiglottis and get a nice view of the cords as you go in. I guess you're supposed to pull the miller to the left once you have the view to get the tube in? My biggest issue with going midline is that when there's a floppy epiglottis, I have trouble getting underneath it and pulling it up for a good view of the cords. I think I'm pushing it in too far like it's a mac blade and getting into vallecula instead of being able to lift the epiglottis.

 

[deleted162650]

My favorite technique with the Miller blade is to detach it from the laryngoscope handle, throw it in the trash, and then use a Mac blade.

 

[DM27]

I can't give you a good explanation for it, but I have found right paraglossal tends to result in a better first look view than going midline and it largely removes tongue issues from the equation. I generally only go down the center when it's someone who is thin and whose neck I can easily extend completely. In these scenarios I think it's often a chip shot either way.

 

[deleted162650]

it largely removes tongue issues from the equation. I generally only go down the center when it's someone who is thin and whose neck I can easily extend completely.

 

[T-burglar]

My preferred intubation technique with the miller blade is direct laryngoscopy

 

[Urzuz]

It seems that the attendings at my institution fall into 2 camps when it comes to using the Miller blade. A majority (probably over 80%) recommend going in straight down over the midline of the tongue, while a few swear by the right paraglossal approach, where the blade is inserted into the gutter between the tongue and tonsil.

Which technique do you prefer when using the Miller blade, and why?

Right paraglossal. You get the benefit of getting the tongue out of the way (makes a difference in the people with fat tongues) with the superior view the Miller provides. Make sure you leave yourself enough room on the right to place the ETT without obscuring your view.

Leave the Mac blade for the children waiting to sprout hair on their chests.

 

[btbam]

Phillips 1 = the GOAT of peds blades.

 

[facted]

Right side, much better control of the tongue.

There are many intubations I've done with a Miller that I, or others, could not get with a Mac blade. The reverse does not exist. You can't intubate with a Miller, you're not gonna get out with a Mac.

 

[David Moss]

Paraglossal. This is the article I give all my residents on this subject that often changes their perspectives on the Miller blade..

 

[jthedestroyr]

I can't give you a good explanation for it, but I have found right paraglossal tends to result in a better first look view than going midline and it largely removes tongue issues from the equation. I generally only go down the center when it's someone who is thin and whose neck I can easily extend completely. In these scenarios I think it's often a chip shot either way.

This. Right paraglossal almost always beautiful view but looking through that little blade view path. I still prefer MAC but I'm working on things I dont use often at the end of residency.

 

[deleted162650]

This. Right paraglossal almost always beautiful view but looking through that little blade view path. I still prefer MAC but I'm working on things I dont use often at the end of residency.

A good view with no room as the saying goes.

 

[vector2]

Right side, much better control of the tongue.

There are many intubations I've done with a Miller that I, or others, could not get with a Mac blade. The reverse does not exist. You can't intubate with a Miller, you're not gonna get out with a Mac.

If the plan is to DL I go with Miller 2 100% of the time, but I have to begrudgingly admit to some of my colleagues that oropharyngeal clearance and getting redundant tissue out of the way on the 6’2 OSA’er is likely a bit better with the MAC.

 

[anbuitachi]

If the plan is to DL I go with Miller 2 100% of the time, but I have to begrudgingly admit to some of my colleagues that oropharyngeal clearance and getting redundant tissue out of the way on the 6’2 OSA’er is likely a bit better with the MAC.

Why not Miller 3

 

[Urzuz]

Why not Miller 3

The one drawback of the Miller is occasionally having a small space for tube placement after you obtain your view. 98% of folks can be intubated with a Miller 2, and it has a lower profile than the 3...so it only makes sense for that to be your default blade when using a Miller.

I will say though that I do use the 3 if it’s a big dude...sometimes I find I have the entire larnygoscope “hubbed” up to the handle if I use a 2 in those guys.

 

[facted]

A good view with no room as the saying goes.

Never an issue for me. Have someone hold the cheek out of the way if you need more space.

 

[vector2]

Why not Miller 3

You don’t need a Miller 3 unless someone is literally like 6’6 or taller. The geometry and leverage points make it more difficult to use on normal size people, and the blade isn’t really that much wider to help with those with a bunch of redundant tissue.

 

[dhb]

Have someone hold the cheek out of the way if you need more space.

Lesson 1 : "How to impregnate a large female"

 

[Psai]

Lesson 1 : "How to impregnate a large female"

I've always wondered about those fifty bmi g6p4s

 

[deleted162650]

I've always wondered about those fifty bmi g6p4s

Spray and pray.

 

[deleted162650]

Never an issue for me. Have someone hold the cheek out of the way if you need more space.

I have some nurses do that without asking. Always drives me nuts and I slap their hand away. It’s just totally unnecessary with a Mac blade.

 

[facted]

Lesson 1 : "How to impregnate a large female"

Allegedly, there are helpers involved for this. No joke.

 

[jthedestroyr]

Allegedly, there are helpers involved for this. No joke.

Heard same story at our hospital.

 

[2Fast2Des]

Allegedly, there are helpers involved for this. No joke.

Heard the same, isn't that disturbing AF that family and friends are there to assist to do your business?

 

[DrZzZz]

Allegedly, there are helpers involved for this. No joke.

As a resident, had the mother of a patient I was placing an epidural in for labor proudly proclaim she was in the room holding the pannus back when her grand baby was being conceived. Thanks for sharing, m'am.

 

[deleted162650]

As a resident, had the mother of a patient I was placing an epidural in for labor proudly proclaim she was in the room holding the pannus back when her grand baby was being conceived. Thanks for sharing, m'am.

Does that count as a threesome?

 

[Psai]

As a resident, had the mother of a patient I was placing an epidural in for labor proudly proclaim she was in the room holding the pannus back when her grand baby was being conceived. Thanks for sharing, m'am.

I just threw up. Several times.

 

[norski]

I just threw up. Several times.

Queef.

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[deleted162650]

Perhaps a new market for the Bookwalter?

 

[norski]

Does that count as a threesome?

Yes.


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[drmwvr]

Perhaps a new market for the Bookwalter?

Thinking more Montgomery straps. But with the old "ether screen".....

 

[dhb]

Heard the same, isn't that disturbing AF that family and friends are there to assist to do your business?

Miller 4 carriers @narcusprince don't need retraction.

 

[deleted162650]

Miller 4 carriers @narcusprince don't need retraction.

I’ll see your Miller 4 and raise you a Mac 5:

 

[Psai]

I gotta be honest the mac5 looks a little more gentler and inviting than the ramrod miller

 

[dhb]

I’ll see you’re Miller 4 and raise you a Mac 5

Corner pocket G spot.

I was trying to get the thread back on track in case you didn't notice

 

[DoctorCaptain]

I had this same question a few months back after someone showed me a right paraglossal approach for miller blades. Came across this article when I was looking into: Left-molar Approach Improves the Laryngeal View in Patients with Difficult Laryngoscopy | Anesthesiology | ASA Publications. Looks like LEFT paraglossal may be preferred for Mac blades.

 

[narcusprince]

The curve actually helps a bit....at least thats what she said!

 

[epidural man]

My favorite technique with the Miller blade is to detach it from the laryngoscope handle, throw it in the trash, and then use a Mac blade.

Although I don't agree with this (I like the MILLER) - this was pretty funny.

 

[OB1🤙]

I have personally treated a patient with a sub-pannicular cellulitis secondary to imbedded splinters from the 2x4 "pannus bar" that the neighbors had graciously held for the missus so as to allow her gentleman unfettered access to her lady parts.

I'm not sure if it was as eyebrow-raising as the ostomy herpes that I treated a couple months later, but it was close.

#medschoolmemories

 

[OB1🤙]

Oh, and Mac 3 for all.

 

[AdmiralChz]

I have personally treated a patient with a sub-pannicular cellulitis secondary to imbedded splinters from the 2x4 "pannus bar" that the neighbors had graciously held for the missus so as to allow her gentleman unfettered access to her lady parts.

I'm not sure if it was as eyebrow-raising as the ostomy herpes that I treated a couple months later, but it was close.

#medschoolmemories

WOOF aaaand we’re done here folks!

 

[deleted162650]

I'm not sure if it was as eyebrow-raising as the ostomy herpes that I treated a couple months later, but it was close.

Does that count as anal?

 

[deleted162650]

And not too surprising that the dude dirty enough to F a stoma already has herpes.

 

[GravelRider]

Does that count as anal?

No, but a triple team is a real possibility in that scenario.

 

[Psai]

I'm not sure how we got here as a thread or a society but people are just straight up nasty