Stylet preferences

[ButterButter]

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I'm finishing up an anesthesia rotation and wanted to get people's impressions on stylet use. Do you use one? If so, how do you shape it (hockey stick, arcuate, etc.)? If you don't use one, why not? Obviously, this is all personal preference, but I'm curious on y'alls experience early in your career and how that may have influenced how you handle an ET tube.

On my current rotation, the only intubations I've failed at are due to my inability to pass the tube through the cords, despite having at least a grade 2 view. I've been experimenting with stylet shapes, and I'm curious if anyone else had similar problems early in their training.

 

[anbuitachi]

I think 99% of intubations are at least grade 2 view, maybe more.
I use stylet and bend it to a curved L shape. The difficult ones are the ones that are unexpectedly really anterior so it helps. I get the tip thru the cord and start to pull out stylet and advance. '

100% no surprise there if you are having difficulty as a med student. most students do
Experience goes a long way.

 

[deleted162650]

No stylet.

Because stylets are for p*ssies.

 

[Aether2000]

When setting up the OR for the anesthetic, I curl the ETT into a circle with the tip lodged in the connector of the tube. On intubation, pick up the circular construct, pop it open with the fingers of one hand while the blade in place. The curve of the tube will allow Gr III and IV intubations without a stylet. After the tip is through the cords, if the tube does not easily advance, rotate it to change the curve, then advance.

 

[Psai]

Soft suction as a guide

 

[deleted162650]

Soft suction as a guide

That’s what she said.

 

[San Marzano]

I used a stylet for almost every intubation in residency because the tubes came preloaded with them. At my first job out there were no stylets in the tubes and so I stopped using them. If the angle is difficult then I’ll reach for the bougie which I’ve done a handful of times. I should add that the Anesthesia tech support here is phenomenal with a dedicated tech present for every induction. If I need something quickly then I have it at my fingertips within seconds thanks to them.

 

[Urzuz]

When setting up the OR for the anesthetic, I curl the ETT into a circle with the tip lodged in the connector of the tube. On intubation, pick up the circular construct, pop it open with the fingers of one hand while the blade in place. The curve of the tube will allow Gr III and IV intubations without a stylet. After the tip is through the cords, if the tube does not easily advance, rotate it to change the curve, then advance.

Weird, I have never heard of this trick before, but am never opposed to trying something new. How long does it have to stay in the circular position for to get that curve?

 

[Cryc_to_the_point]

Weird, I have never heard of this trick before, but am never opposed to trying something new. How long does it have to stay in the circular position for to get that curve?

This is how we prepped for all of our nasal tubes in the field.

 

[partydoc]

I rotate between the hockey stick and the circle algosdoc mentioned

Weird, I have never heard of this trick before, but am never opposed to trying something new. How long does it have to stay in the circular position for to get that curve?

set it up when yourey getting your room ready

 

[Urzuz]

I rotate between the hockey stick and the circle algosdoc mentioned

set it up when yourey getting your room ready

I get my room ready while the nurses are hooking the patient up to monitors, one minute before I induce them.

 

[anbuitachi]

I used a stylet for almost every intubation in residency because the tubes came preloaded with them. At my first job out there were no stylets in the tubes and so I stopped using them. If the angle is difficult then I’ll reach for the bougie which I’ve done a handful of times. I should add that the Anesthesia tech support here is phenomenal with a dedicated tech present for every induction. If I need something quickly then I have it at my fingertips within seconds thanks to them.

I get my room ready while the nurses are hooking the patient up to monitors, one minute before I induce them.

Must be nice to have good tech support.

 

[San Marzano]

Must be nice to have good tech support.

I love it, almost makes me feel like a real doctor.

 

[agammaglobulin]

I don't think there is a correct answer for this, whatever works for you. I stylet every tube. Why? Habit from residency probably. An attending told me if the airway is challenging, you want a stylet. Most of the time it's unnecessary, but theoretically you will not be looking for a stylet when you want one. Dr. San Marzano is an excellent anesthesiologist is probably correct that you don't have to rely on the stylet when you have other stuff available.

That being said, ENT surgeons will tell you they see vocal cord trauma from stylets/intubations. So if you're going to use a stylet, be careful not to advance the tube through the vocal cords and in to the trachea with stylet in place. Unless you are a CRNA, then just shove that thing, stylet and all, into the trachea before the paralytic kicks in. That way you know the vocal cords aren't all the way open and are sure to bang the $h!t out of them.

 

[Noyac]

Just as agammaglobin stated, there is no right or wrong per se’. With that being said, I don’t use stylets. I don’t bend the tube in funny formations. I open it up pull it out and put it in. Most of the time. When I believe the airway might be difficult, as in extremely anterior for example, then I will load a styler but I don’t shape it. Tubes are shaped like they are deformed a reason. I assume, because I’ve never looked into it, that this reason is because this was the optimal shape for success. So I leave it that way until I verify for myself that I need a different shape.

Personally, I’d recommend learning to use it like it is. KISS!!!

 

[Velefunt]

No stylet ordinarily.

"Hockey stick" most typically when very anterior glottis calls for it.

On occasion a "candy cane" for Glidescope intubations which have very anterior glottis that the regular rigid "J stylet" will not reach.

 

[fakin' the funk]

When setting up the OR for the anesthetic, I curl the ETT into a circle with the tip lodged in the connector of the tube. On intubation, pick up the circular construct, pop it open with the fingers of one hand while the blade in place. The curve of the tube will allow Gr III and IV intubations without a stylet. After the tip is through the cords, if the tube does not easily advance, rotate it to change the curve, then advance.

Yes, I'm always getting those trivial little grade 4 views that my special trick bending the ****ing ET tube fixes.

BULL ****

Why are you getting Grade 4 views?
Why are you placing the tube when you can't see where it's going?
How do you know exactly what your tube trick is doing to the tip of the tube if by definition you can't see it?

 

[Aether2000]

We all have some patients that have a Gr III airway on DL, and occasionally a Gr IV. The curled tube technique allows placement of a soft tube blind through the glottis while the Glidescope is being acquired. Gr IV- have done one with this technique. But experience with the technique takes a little time since the tube must stay coiled for several minutes in order to achieve the curvature desired. It will not work for everyone but works great for me, and I have had to use a stylet only a few times.

 

[Noyac]

[QUOTE="fakin' the funk, post: 19927658, member: 51122"Why are you placing the tube when you can't see where it's going?
How do you know exactly what your tube trick is doing to the tip of the tube if by definition you can't see it?[/QUOTE]
I do this all the time. At least once a day.
If I can’t see the cords without applying more force but I know where they are then I pass the tube. I’d rather gently slip the tube in the trachea than crank on the pt just to watch the tube pass through. If I can’t pass it gently then I crank a little more.
My point is, I don’t think you necessarily need to see the cords every time in order to safely intubate.

 

[fakin' the funk]

I do this all the time. At least once a day.
If I can’t see the cords without applying more force but I know where they are then I pass the tube. I’d rather gently slip the tube in the trachea than crank on the pt just to watch the tube pass through. If I can’t pass it gently then I crank a little more.
My point is, I don’t think you necessarily need to see the cords every time in order to safely intubate.

We don't disagree. And your point is a non sequitur. We know that a grade 3 view will often give you the info that you need to pass the time with a reasonable certainty that it is tracheal. It's a bit silly to call it "cranking" on the patient as opposed to "slipping" the tube in - wow, I'm so impressed with your technique.

 

[fakin' the funk]

We all have some patients that have a Gr III airway on DL, and occasionally a Gr IV. The curled tube technique allows placement of a soft tube blind through the glottis while the Glidescope is being acquired. Gr IV- have done one with this technique. But experience with the technique takes a little time since the tube must stay coiled for several minutes in order to achieve the curvature desired. It will not work for everyone but works great for me, and I have had to use a stylet only a few times.

Grade 4s especially, and Grade 3s to a lesser degree, are highly predictable. Why isn't the Glidescope in the room?

 

[deleted162650]

Yes, I'm always getting those trivial little grade 4 views that my special trick bending the ****ing ET tube fixes.

BULL ****

Why are you getting Grade 4 views?
Why are you placing the tube when you can't see where it's going?
How do you know exactly what your tube trick is doing to the tip of the tube if by definition you can't see it?

We don't disagree. And your point is a non sequitur. We know that a grade 3 view will often give you the info that you need to pass the time with a reasonable certainty that it is tracheal. It's a bit silly to call it "cranking" on the patient as opposed to "slipping" the tube in - wow, I'm so impressed with your technique.

Grade 4s especially, and Grade 3s to a lesser degree, are highly predictable. Why isn't the Glidescope in the room?

And they call me salty. . .

 

[Noyac]

We don't disagree. And your point is a non sequitur. We know that a grade 3 view will often give you the info that you need to pass the time with a reasonable certainty that it is tracheal. It's a bit silly to call it "cranking" on the patient as opposed to "slipping" the tube in - wow, I'm so impressed with your technique.

Hey, just because your post was quoted and rebutted doesn’t mean you need to defend yourself with insults (or snide comments) towards the poster. And it doesn’t mean that I was taking a personal shot at you. I was just commenting with reference to your post. Why are people so damn defensive here?
FTF, you go way back on this forum as do I. Let’s discuss things professionally please. This isn’t a nursing forum, (not taking a shot at you).

 

[Arch Guillotti]

Let’s discuss things professionally please. This isn’t a nursing forum, (not taking a shot at you).

Who are you taking the shot at then?







😉

 

[fakin' the funk]

Hey, just because your post was quoted and rebutted doesn’t mean you need to defend yourself with insults (or snide comments) towards the poster. And it doesn’t mean that I was taking a personal shot at you. I was just commenting with reference to your post. Why are people so damn defensive here?
FTF, you go way back on this forum as do I. Let’s discuss things professionally please. This isn’t a nursing forum, (not taking a shot at you).

I called your comment "a bit silly" and sarcastically mocked your self-congratulatory tone, which was irrelevant to my post anyway. That qualifies as "so damn defensive," right on.

 

[Aether2000]

I trained in an era long before glidescopes, Bullards or wu-scopes. We developed several skills for difficult intubations that did not rely on direct visualization of the cords. Of course glidescopes are nice but they are not universally available in surgery centers and in hospitals with 10 times the anesthesia locations as glidescopes or equivalents. For an anticipated challenging intubation I do not require a glidescope to be present especially when acquisition of such would delay the surgery and given my bag of intubation tricks I use instead. I appreciate modern technology but am not a slave to it.

 

[Noyac]

Who are you taking the shot at then?

Well actually, I’m not taking a shot at anyone. Did it seem as tho I was?

 

[Noyac]

I called your comment "a bit silly" and sarcastically mocked your self-congratulatory tone, which was irrelevant to my post anyway. That qualifies as "so damn defensive," right on.

Ok fine.
I’m not usually called silly, so I don’t have a lot of experience in that arena.

 

[deleted697535]

After about 3000 intubations I'd say my limited experience tells me none of that matters a lot if you're initial positioning is wrong.

Patients head should be 1 inch from the top of the table.
Pillow under head and tops of shoulder.
Flannel sheets under pillow and down to mid scapula.
Last thing I say to all my potentially tricky patients before they go off to sleep is 'lift your chin right up in the air for me'.
Then you must 'manage' the tongue. Literally shove it back into the mouth with your hand if it is protruding onto the teeth. This is something no one ever spoke to me about but I think it's very important


Use your assistant well. I always ask my assistant nurse to pull down the corner of the mouth. Another gem. The tube should come in from right to middle so you can at all times see the little piece of glottic opening. Never insert a tube down the middle so that you lose your view.

And if my assistant has cricoid on and I have no view, I get them to take cricoid off


If you do all those things I don't think youll need a stylet basically ever. Maybe once a year. The natural curve of the tube is enough.

As for shape, I just shape it the same as the glidescope stylet. I don't think it really matters.

If you are trying to use a stylet to make up for piss poor positioning(maybe you have all.that down already) that I described earlier on, you are going to lose.

Anyway that's just my 2cent.
A stylet is a bit of a dangerous weapon. In the last 3 weeks alone I've seen 3 traumatic intubations with sliced vocal cords and 1 lead to a tef likely caused by the stylet. So be careful

 

[San Marzano]

I trained in an era long before glidescopes, Bullards or wu-scopes. We developed several skills for difficult intubations that did not rely on direct visualization of the cords. Of course glidescopes are nice but they are not universally available in surgery centers and in hospitals with 10 times the anesthesia locations as glidescopes or equivalents. For an anticipated challenging intubation I do not require a glidescope to be present especially when acquisition of such would delay the surgery and given my bag of intubation tricks I use instead. I appreciate modern technology but am not a slave to it.

So since you’re not a slave to modern technology does that mean you’re using ether and masking your patients with a mapleson circuit the whole case so that you don’t have to use these newfangled ventilator doo-hickies or sevo-vapo-whatchamacallits?

 

[nimbus]

A stylet is a bit of a dangerous weapon. In the last 3 weeks alone I've seen 3 traumatic intubations with sliced vocal cords and 1 lead to a tef likely caused by the stylet. So be careful

Wow! That’s a lot. I’ve heard of one stylette injury at another hospital in 25 years.

 

[fakin' the funk]

I trained in an era long before glidescopes, Bullards or wu-scopes. We developed several skills for difficult intubations that did not rely on direct visualization of the cords. Of course glidescopes are nice but they are not universally available in surgery centers and in hospitals with 10 times the anesthesia locations as glidescopes or equivalents. For an anticipated challenging intubation I do not require a glidescope to be present especially when acquisition of such would delay the surgery and given my bag of intubation tricks I use instead. I appreciate modern technology but am not a slave to it.

Semi tangent here.

Heard this sentiment so many times during my short career. "What if you have to do a central line and there's no ultrasound around? What if there no Glidescope around?" Guess what? Never happened. These have become the standard of care for central lines and difficult intubations in that time. Getting the Glidescope isn't a delay; it's good care.

 

[deleted59964]

wow - so this thread has shown we all have techniques that enable us to intubate well.
good work everyone

 

[Psai]

After about 3000 intubations I'd say my limited experience tells me none of that matters a lot if you're initial positioning is wrong.

Patients head should be 1 inch from the top of the table.
Pillow under head and tops of shoulder.
Flannel sheets under pillow and down to mid scapula.
Last thing I say to all my potentially tricky patients before they go off to sleep is 'lift your chin right up in the air for me'.
Then you must 'manage' the tongue. Literally shove it back into the mouth with your hand if it is protruding onto the teeth. This is something no one ever spoke to me about but I think it's very important


Use your assistant well. I always ask my assistant nurse to pull down the corner of the mouth. Another gem. The tube should come in from right to middle so you can at all times see the little piece of glottic opening. Never insert a tube down the middle so that you lose your view.

And if my assistant has cricoid on and I have no view, I get them to take cricoid off


If you do all those things I don't think youll need a stylet basically ever. Maybe once a year. The natural curve of the tube is enough.

As for shape, I just shape it the same as the glidescope stylet. I don't think it really matters.

If you are trying to use a stylet to make up for piss poor positioning(maybe you have all.that down already) that I described earlier on, you are going to lose.

Anyway that's just my 2cent.
A stylet is a bit of a dangerous weapon. In the last 3 weeks alone I've seen 3 traumatic intubations with sliced vocal cords and 1 lead to a tef likely caused by the stylet. So be careful

3 traumatic intubations? Your people need an inservice in intubating or something.

 

[Southpaw]

A stylet is a bit of a dangerous weapon. In the last 3 weeks alone I've seen 3 traumatic intubations with sliced vocal cords and 1 lead to a tef likely caused by the stylet. So be careful

I don’t think the stylet is the problem. I don’t typically use one, but I haven’t seen any of the above in 9 years, 4 of which were in residency among relatively inexperienced physicians, where stylets were more routinely used.

 

[Aether2000]

For those that claim video laryngoscopy is the standard of care, I would refer you to the ASA Practice Guidelines 2013 for management of the Difficult Airway. While videolaryngoscopy is one of the options, it is not the only option and is certainly not considered the only standard of care for intubation of the difficult airway

 

[Hoya11]

I'm finishing up an anesthesia rotation and wanted to get people's impressions on stylet use. Do you use one? If so, how do you shape it (hockey stick, arcuate, etc.)? If you don't use one, why not? Obviously, this is all personal preference, but I'm curious on y'alls experience early in your career and how that may have influenced how you handle an ET tube.

On my current rotation, the only intubations I've failed at are due to my inability to pass the tube through the cords, despite having at least a grade 2 view. I've been experimenting with stylet shapes, and I'm curious if anyone else had similar problems early in their training.

I use a stylet every time. Nothing worse than trying to look slick, unexpectedly encountering some difficulty, and then trying to manipulate the tube with no stylet into the challenging airway. Sometimes you might get it, but sometimes you miss or have to stop and bag and put the stylet in.. and then you think why did I do this again? Not worth it. Im not concerned about the minimal risk of "trauma" from the stylet, im concerned about getting the tube in the airway.

I often see the steep hockey stick and never use it personally. such a steep angle can lead the tube to go UP into the anterior tracheal wall and it wont pass smoothly. Instead, I have a very subtle angle on the stylet, its almost straight, and that way as I am trying to overcome minor resistance or a difficult angle, the tube is going FORWARD, not up, into the trachea. I teach students and very often this makes them successful on their second attempt where the first they can not pass the tube due to the "angle".

 

[hankbb02]

I use a stylet every time. Nothing worse than trying to look slick, unexpectedly encountering some difficulty, and then trying to manipulate the tube with no stylet into the challenging airway. Sometimes you might get it, but sometimes you miss or have to stop and bag and put the stylet in.. and then you think why did I do this again? Not worth it. Im not concerned about the minimal risk of "trauma" from the stylet, im concerned about getting the tube in the airway.

I often see the steep hockey stick and never use it personally. such a steep angle can lead the tube to go UP into the anterior tracheal wall and it wont pass smoothly. Instead, I have a very subtle angle on the stylet, its almost straight, and that way as I am trying to overcome minor resistance or a difficult angle, the tube is going FORWARD, not up, into the trachea. I teach students and very often this makes them successful on their second attempt where the first they can not pass the tube due to the "angle".

There is no "right way" to pass the ETT. I don't use a stylet with DL, ever. RSI's, no stylet. Predicted difficult laryngoscopy, no stylet. I pre-curve the tube as described above and have learned how to pass it through the glottis in anterior airways and straightforward airways alike. Sometimes I need to straighten the tube on the corner of the mouth or rotate it to pass through the glottis. Once or twice a year I will request a bougie because I need more force to lift a large epiglottis but I will never stop to put a stylet in the tube. For me it's not about looking slick. It just doesn't add anything. I have a much greater range of tube mobility with the memory of the plastic than I do with a stylet that I curved before laryngoscopy.

 

[Noyac]

So since you’re not a slave to modern technology does that mean you’re using ether and masking your patients with a mapleson circuit the whole case so that you don’t have to use these newfangled ventilator doo-hickies or sevo-vapo-whatchamacallits?

Is this for real?

 

[Noyac]

3 traumatic intubations? Your people need an inservice in intubating or something.

No ****. I haven’t seen one of these issues in over 10yrs. But we are all docs in my group, no nurses. I guess that can make a difference even in the monkey skills.

 

[Noyac]

I don’t know what training is like these days but I recall having my attending put me in unusual situations and then having to work my way out of it. For example, I would set up my room then go see the pt. My attending would go into the room and remove all the stylets. That’s one way to learn how to intubate without one. Another time, an attending removed all the batteries from my laryngoscope handles. I pulled the over head OR light into my field of view and managed to intubate. Attending gave me good marks for that one. Another one would pull the power on the machine in the middle of a case. I believe the surgeons were on to his antics since they just laughed when he did it. Times may have been different then but I sure appreciated it.
Oh and another attending would only give me a 27g Pencan for spinals and no introducer.

 

[Psai]

I don’t know what training is like these days but I recall having my attending put me in unusual situations and then having to work my way out of it. For example, I would set up my room then go see the pt. My attending would go into the room and remove all the stylets. That’s one way to learn how to intubate without one. Another time, an attending removed all the batteries from my laryngoscope handles. I pulled the over head OR light into my field of view and managed to intubate. Attending gave me good marks for that one. Another one would pull the power on the machine in the middle of a case. I believe the surgeons were on to his antics since they just laughed when he did it. Times may have been different then but I sure appreciated it.
Oh and another attending would only give me a 27g Pencan for spinals and no introducer.

I have had my stylets pulled out and also tiny needle with no introducer done to me. Another thing that happened my first month was disconnecting the airway in the middle of the case when I wasn't looking. Nearly had a panic attack when I saw the machine not working.

 

[sigrhoillusion]

I probably use a stylet 95% of the time just out of habit from residency. That being said I don't put a bend on my tube. My thought is that if I'm getting the patient in appropriate position and have a grade 1 view, then I should have a straight shot so no need for a bend. If for some reason the glottis is a little anterior or I have a GRade3-4 view I can quickly with one hand while still keeping my view bend the tube into position. Easier to put a bend in with one hand then take the bend out. I can't tell you the amount of times I've come into a room to induce a patient with a CRNA and they have the end of the tube at the sharpest angle. the ETT looks like an "L", heck even a "J"... And if anything they put the ETT in the mouth and you can see them readjusting the tube up and down and sideways to try and get the tip between the cords, cause the angle the created is banging up on the top. They either struggle to maneuver it in, or they have to take the ETT out and reshape it. IF that happens I tend to grab the tube myself and straighten it so they don't have to readjust/remove the blade in order to do it themselves.

 

[pgg]

I often see the steep hockey stick and never use it personally. such a steep angle can lead the tube to go UP into the anterior tracheal wall and it wont pass smoothly. Instead, I have a very subtle angle on the stylet, its almost straight, and that way as I am trying to overcome minor resistance or a difficult angle, the tube is going FORWARD, not up, into the trachea. I teach students and very often this makes them successful on their second attempt where the first they can not pass the tube due to the "angle".

I try to teach residents to put the styletted tube just past the cords, keep their view, and have the nurse pull the stylet before passing the tube the rest of the way into the trachea, to avoid exactly that anterior scraping from the hockey stick tube.


As for the stories of outright injuries from stylets that were posted upthread ... ... I guess anybody can injure anyone with hamfisted bad technique. Those people are probably more of a menace with the laryngoscope blade itself than the stylet.

I stylet all of my tubes. I don't see a reason not to. Every once in a while I'm glad it's there, but I can't say it's ever hurt me.

I could probably do a better job optimizing position for every patient and turn most of my grade 2 & 3 views into grade 1s ... but the tubes go in regardless.


On a related subject, bougies are a great semi-blind technique. Trachea ring bumps are very distinct. It's a rare unexpected grade 4 view that can't be easily intubated by sticking a bougie where you know the trachea ought to be.

 

[Noyac]

I

I could probably do a better job optimizing position for every patient and turn most of my grade 2 & 3 views into grade 1s ... but the tubes go in regardless.

I was thinking the exact same thing about positioning.

 

[sigrhoillusion]

I was thinking the exact same thing about positioning.

Yea, definitely had a multiple DL patient with MAC and Miller blades by CRNA and I a few days ago, which I was able to finally get a Grade 2 view on after repositioning patient just as glidescope was brought into room by anesthesia tech... Definitely should have ramped this patient from the get go.

 

[deleted162650]

[QUOTE="pgg, post: 19934258, member: 84904]
I stylet all of my tubes.[/QUOTE]

P*ssy.

😉

 

[2Fast2Des]

I have had my stylets pulled out and also tiny needle with no introducer done to me. Another thing that happened my first month was disconnecting the airway in the middle of the case when I wasn't looking. Nearly had a panic attack when I saw the machine not working.

Had one attending pull the ETT while patient was emerging through stage 2 to teach me how to manage laryngospasm, that was fun

 

[deleted162650]

Had one attending pull the ETT while patient was emerging through stage 2 to teach me how to manage laryngospasm, that was fun

We had an attending that would give you a break and secretly sabotage your machine/set-up while you were gone and leave you to figure it out upon your return.

 

[anbuitachi]

Had one attending pull the ETT while patient was emerging through stage 2 to teach me how to manage laryngospasm, that was fun

so did the patient go into laryngospasm?