Miller blade

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Anyone have any instances were they strongly prefer a straight blade over a MAC. I have yet to have an instance we’re i couldn’t intubate someone with a MAC and switched to a Miller, only because video scopes are so easily available.

From my experience the straight blades seem to get a more complete view of the glottis most of the time, are better for small mouth openings and for a bigger epiglottis. Do people switch blades occasionally or do you all just use the same blade for everyone?
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I wonder why all the development and progress in instruments to incubate have incorporated a Mac shape.....
 
Many of the CRNA's I've worked with are quick to switch blades if they get a suboptimal view. I have never seen a physician do this.

As an extreme novice, I strongly prefer the MAC and notice that younger physicians tend to as well. Very much seems to correlate with where you were trained.
 
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I prefer the Miller on pedi cases.
But I don’t always use as it was intended. I will use it like a MAC if I can get the view I need. Then if I can’t get that view, I will advance beyond the epiglottis and pick it up as it was intended.

Otherwise, everyone else I intubate with a MAC.
 
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Pre video laryngoscopy, for me it was Miller for everything except double lumen tubes.
 
Miller 2 get it through

Straight blade 4 lyfe
 
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I used mostly a Mac in residency, switched to a Miller at the end, and I've been using that almost exclusively for the past several years. Where I'm in fellowship now, though, everyone uses Macs, and I'm the oddball that requests a Miller when tubing in the unit. I stress with the residents getting comfort with both blades, but their staff in the OR mostly all trained here, and also almost exclusively use Macs.

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Mehd School said:
Many of the CRNA's I've worked with are quick to switch blades if they get a suboptimal view. I have never seen a physician do this.

As an extreme novice, I strongly prefer the MAC and notice that younger physicians tend to as well. Very much seems to correlate with where you were trained.
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Their error is likely wanting to optimize an already adequate view. We use a lot of CMACs for training. I see, somewhat, what they’re seeing. They say they have a grade 2 view (1 on the screen) and try to improve the view. Why? Just put the GD tube in and be done with it.

I see the same with the glidescope. They try to optimize an adequate view for no reason, get too close, and make it harder to manipulate the tube and intubate successfully.

I intubate with a grade 2 view all the time. Miss lifting the epiglottis? Just put the tube in. There’s the air hole, tube goes there. It ain’t an airway exam.

--
Il Destriero
 
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dipriMAN said:
Anyone have any instances were they strongly prefer a straight blade over a MAC. I have yet to have an instance we’re i couldn’t intubate someone with a MAC and switched to a Miller, only because video scopes are so easily available.

From my experience the straight blades seem to get a more complete view of the glottis most of the time, are better for small mouth openings and for a bigger epiglottis. Do people switch blades occasionally or do you all just use the same blade for everyone?
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Blade of Choice MAC 3 ... if no success
Glidescope 4 (never the 3)

Im not going to waste time with a miller blade, if its tough, I just want the tube in and Im going to use the GS and be done..

If still no success (very rare) then Ill get fancy and do FO scope with glidescope, intubating LMA plus or minus FO, but at that point Im thinking about calling for help..

Rarely for a young pedi patient (0-1) I will use a miller 0 or 1. That's pretty much it.. I think its going the way of the AFOI
 
Hoya11 said:
Blade of Choice MAC 3 ... if no success
Glidescope 4 (never the 3)

Im not going to waste time with a miller blade, if its tough, I just want the tube in and Im going to use the GS and be done..

If still no success (very rare) then Ill get fancy and do FO scope with glidescope, intubating LMA plus or minus FO, but at that point Im thinking about calling for help..

Rarely for a young pedi patient (0-1) I will use a miller 0 or 1. That's pretty much it.. I think its going the way of the AFOI
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I'm trying to avoid hyperbole, but I couldn't help but shout out holy **** when I read this.

I spend a few extra seconds positioning properly, use a miller, and usually have no trouble. If there's a lot of redundant tissue I'll use a MAC just to make it easier to move things out of the way.

I don't understand why people are so hesitant to do awake fiberoptics. It's in your wheelhouse, just take an extra 10-15 minutes and save yourself the stress.
 
dipriMAN said:
Anyone have any instances were they strongly prefer a straight blade over a MAC. I have yet to have an instance we’re i couldn’t intubate someone with a MAC and switched to a Miller, only because video scopes are so easily available.

From my experience the straight blades seem to get a more complete view of the glottis most of the time, are better for small mouth openings and for a bigger epiglottis. Do people switch blades occasionally or do you all just use the same blade for everyone?
Click to expand...

How well does this work for you on a 3kg baby?
 
I don't intubate a lot now a days. Often, if someone before me has failed, they lack the vocabulary to explain why exactly, and what they saw or didn't see. So I grab the scope they didn't use. My success rate is very high. Is it the different scope, or different person (nurse care - every heartbeat, every breath. :rolleyes:)

When I did a lot of intubations, Mac was Mon/Wed/Fri. Miller was Tues/Thurs/Sat. Sunday was whatever was closest to the patient. I just wanted to be proficient with both.
 
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Ipassgas said:
I don't intubate a lot now a days. Often, if someone before me has failed, they lack the vocabulary to explain why exactly, and what they saw or didn't see. So I grab the scope they didn't use. My success rate is very high. Is it the different scope, or different person (nurse care - every heartbeat, every breath. :rolleyes:)

When I did a lot of intubations, Mac was Mon/Wed/Fri. Miller was Tues/Thurs/Sat. Sunday was whatever was closest to the patient. I just wanted to be proficient with both.
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So they always feel they would have got the tube if they’d used the other blade.
I’d be demonstrating their inferiority a bit more clearly by using the same blade
 
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Miller 2 bang it through.


In residency everyone used a Mac except me. In private practice every single one of my partners (older docs) uses a miller. I’ll just say that once I stopped using the fishhook my success rate approached virtually 100%. I cant even remember the last time I had to resort to more than a mil deuce and a bougie
 
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Fun fact, the miller blade was not necessarily designed to lift the epiglottis up, it's more about the line of view than the actual technique:

“The epiglottis is visualized and raised slightly to exposure the cords or, if the operator desires, the tip of the blade maybe placed in front of the epiglottis and raised sufficiently to visualize the cords after the method of Macintosh.” - From Miller himself

Also, there is no real benefit in using a Miller vs. Mac in pediatric airways:
Getting Things Straight

More gold from Miller:

“The blade is inserted in the right side of the mouth, pushing the tongue to the left.”

Placing the Miller blade in the middle of the mouth is actually not what it was intended for, neither is trying to shove the tube through the blade.
 
Steege305 said:
I'm trying to avoid hyperbole, but I couldn't help but shout out holy **** when I read this.

I spend a few extra seconds positioning properly, use a miller, and usually have no trouble. If there's a lot of redundant tissue I'll use a MAC just to make it easier to move things out of the way.

I don't understand why people are so hesitant to do awake fiberoptics. It's in your wheelhouse, just take an extra 10-15 minutes and save yourself the stress.
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What stress are you saving by putting a patient through afoi ? If it needs to be done fine but glidescope has mad it often not necessary esp after an awake look
 
Hoya11 said:
What stress are you saving by putting a patient through afoi ? If it needs to be done fine but glidescope has mad it often not necessary esp after an awake look
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I’ve never done an awake look. Is this common?
 
Hoya11 said:
What stress are you saving by putting a patient through afoi ? If it needs to be done fine but glidescope has mad it often not necessary esp after an awake look
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A side point but what stress do you put your patients thru doing afoi? Most of mine don't remember any of it.

An awake look is a nice technique. The new metal glidescope blades are not much bigger than a guedel airway so it's not much more stimulation. Just use the same mix you use for afoi. Then slip the glidescope in.

You can even put the tube in too, line it up with the cords via glidescooe view as the patient is still semi awake and breathing. Once you're happy bang in roc followed by prop.

Or a half dose of sux followed by prop. It's amazing how little sux you need to paralyse the cords only when the glidescope already gives you the view. The sux dose for that seems to be much less than what's needs to paralyse the jaw enough to let you do DL
 
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When an surgeon does supraglottic access laryngeal surgery, what type of exposure device does he/she use? Straight or curved?
 
As a sidenote from what i've seen in Europe it's 99.9% Mac, some places don't even have Miller blades.
 
Hoya11 said:
Blade of Choice MAC 3 ... if no success
Glidescope 4 (never the 3)

Im not going to waste time with a miller blade, if its tough, I just want the tube in and Im going to use the GS and be done..

If still no success (very rare) then Ill get fancy and do FO scope with glidescope, intubating LMA plus or minus FO, but at that point Im thinking about calling for help..

Rarely for a young pedi patient (0-1) I will use a miller 0 or 1. That's pretty much it.. I think its going the way of the AFOI
Click to expand...

Interesting that you say this because I'm always a Glide 3 no matter the size of the patient. I only use 4 if the tech forgets to restocks 3

Regarding the OP, I used both s I'm comfortable with both. I was trained on Mac 3 so when I started on my own I forced myself to get better with the Miller 2 so I was comfortable with it.

My flow is
MAC3 / Mill 2 vs Glide 3
 
A Miller can get you a view of the cords in certain airways where the MAC may only get you a grade 3 view. But MAC's will get you the better quality view which is why they are generally better when placing DLT's. Glidescopes/Mcgraths are so readily available nowadays so it doesn't matter so much. Just keep in mind that if you do enough cases, on rare occasion you may encounter an airway that can't be intubated with any sort of blade/video laryngoscope. It's important to know and have the skills to manage and secure the airway at this point.
 
Ezekiel2517 said:
A Miller can get you a view of the cords in certain airways where the MAC may only get you a grade 3 view. But MAC's will get you the better quality view which is why they are generally better when placing DLT's. Glidescopes/Mcgraths are so readily available nowadays so it doesn't matter so much. Just keep in mind that if you do enough cases, on rare occasion you may encounter an airway that can't be intubated with any sort of blade/video laryngoscope. It's important to know and have the skills to manage and secure the airway at this point.
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Hammering this point home. It's also important the techs and nurses know what to do when you've encountered a difficult airway. I work someone where many times there isn't help walking around or it may be 20 mins away. When I do "practice airways" with some of the advanced equipment I always get once of the nurses involved so they know what i mean when "I want this airway" or "lift the chin like this" so they're not fumbling around when the stuff is really hitting the fan.
 
Hung like a 4 miller...... I exclusively use the mac blade my 90% of the time I use the mac 3.5 if that does not work I may go up or down. After that its the glide.... if that doesn’t work glide bougie..... glide fiber......
 
dipriMAN said:
Anyone have any instances were they strongly prefer a straight blade over a MAC. I have yet to have an instance we’re i couldn’t intubate someone with a MAC and switched to a Miller, only because video scopes are so easily available.

From my experience the straight blades seem to get a more complete view of the glottis most of the time, are better for small mouth openings and for a bigger epiglottis. Do people switch blades occasionally or do you all just use the same blade for everyone?
Click to expand...
I have almost never had a patient I couldn't intubate with a Miller and could intubate with a MAC. The reverse happened frequently.

Since I left residency, I 100% use the Miller on first attempt (even for patients who you think you might need video scope for). I rarely need to use a videoscope, even on obese patients. I liberally ramp patients which I think helps tremendously.
 
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Loved my Miller 4s but in my current hospital, they are rare. Glidescope/ C-mac is not always available given that we have 3 for 40 ORs in far flung locations.
 
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narcusprince said:
Hung like a 4 miller...... I exclusively use the mac blade my 90% of the time I use the mac 3.5 if that does not work I may go up or down. After that its the glide.... if that doesn’t work glide bougie..... glide fiber......
Click to expand...

Mmm I've heard of digital intubations but this is a bit different
 
Be able to use both, everywhere I’ve worked often one or the other was either unavailable or sterilized so many times it was like intubating in a pitch black cave.

Fun tip, if that happens turn out the lights, place your iPhone light on the thyroid cartilage and follow the yellow brick road (or head towards the light).
 
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Steege305 said:
I don't understand why people are so hesitant to do awake fiberoptics. It's in your wheelhouse, just take an extra 10-15 minutes and save yourself the stress.
Click to expand...

While I find them easy to do most of the time, I find the need to do one only once every several thousand cases at a massive level 1 trauma center filled with fatties.
 
AdmiralChz said:
Be able to use both, everywhere I’ve worked often one or the other was either unavailable or sterilized so many times it was like intubating in a pitch black cave.

Fun tip, if that happens turn out the lights, place your iPhone light on the thyroid cartilage and follow the yellow brick road (or head towards the light).
Click to expand...
Does that really work?
 
I use a Mac 4 for almost all of my adult intubations in the ER. Miller almost always for the peds.

In the adults sometimes I’ll swith it up but it’s really rare for me to encounter an intubation where I can’t get by just fine with Mac +\- Bougie. I just love the view I get with the 4 and have plenty of blade to lift epiglottis if I need to. I realize this might be suboptimal for the laryngoscopy purists out there but hey...it works for me.
 
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I only really *need* a Mac 4 for about 1 in 50-100 adult intubations, but it's fine if that's what works for you. It's like a Miller 3, probably overkill most of the time, but useful when you really need it.
 
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I’m just waiting for the day I need to break out this bad boy:

91D3865A-B985-46A6-A4CB-02CEED3C357C.jpeg
 
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A while back I got randomly pulled into a room for an emergent case and was having trouble getting a good view on a guy with a Mac 3 and so I asked for the Miller 2 (the tech happened to be in the room at the time, was great). When she looked in the drawer there wasn't one so she asked what I wanted, and I said give me the Miller 3. My attending instantly started heckling me about it but allowed me to proceed while continuing the heckling.

Best view I've ever gotten on anyone.

I fell in love with the longsword that day.
 
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DocVapor said:
I fell in love with the longsword that day.
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Why stop at a 3?

67BE1B0C-88BB-47FE-8850-C346538E5768.jpeg


At least I’m covered if I ever find a giraffe on my table.


Honestly, there’s a Mac 5 and Miller 4 in every room here. :wtf:
 
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Twiggidy said:
Mac 3 -> Miller 2 --> Glidescope --> Fiberoptic ==> knife
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I’d say Miller 2 —> Glidescope —> Fiberoptic —> knife : unless a CRNA or resident has already dirtied up a Mac in which case I’ll use it.

Anyway, the Mac 3 would never be downstream of the Miller 2 because you can never get it with a Mac 3 if you can’t get it with a Miller 2. It’s because the Miller is the superior blade.
 
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SaltyDog said:
Why stop at a 3?

View attachment 235867

At least I’m covered if I ever find a giraffe on my table.


Honestly, there’s a Mac 5 and Miller 4 in every room here. :wtf:
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I've used that Miller 4 monster once, just for kicks. Unwieldy beast. That being said, had an extremely difficult floor airway the other day, coding - GIB + emesis. After a few unsuccessful attempts (still getting CPR, no ROSC), an ICU fellow wanted a look. Let em have it. Goes in with the Mil 3, which was the last blade used. After a short struggle, dude asked for a Mil 4. Since the patient wasn't 11 feet tall, I politely told him to get the * out the way and hand the blade back. Can't think of another request that further demonstrates your lack of ability to handle an airway. Maybe the code runner asking for the glide when the patient is spewing blood and feculent material out the mouth?
 
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