When did you get confident with DL intubation?

[foodie83]

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Hi,
I'm an intern who will be starting my CA1 year in July. I'm currently doing a month-long anesthesia elective, and find that DL intubation is still somewhat difficult for me. Obviously I don't have near the experience compared to seasoned attendings or even residents, but I feel somewhat discouraged because I don't know if other anesthesiology residents- when they were med students or even interns- felt like DL intubation was a breeze. Is it normal to still struggle a bit until you REALLY start to do intubations every day? Did anyone else feel this way? I just hope I'm not a total spaz and way behind my fellow CA1's when we start in July. Any feedback is appreciated!

 

[pgg]

Hi,
I'm an intern who will be starting my CA1 year in July. I'm currently doing a month-long anesthesia elective, and find that DL intubation is still somewhat difficult for me. Obviously I don't have near the experience compared to seasoned attendings or even residents, but I feel somewhat discouraged because I don't know if other anesthesiology residents- when they were med students or even interns- felt like DL intubation was a breeze. Is it normal to still struggle a bit until you REALLY start to do intubations every day? Did anyone else feel this way? I just hope I'm not a total spaz and way behind my fellow CA1's when we start in July. Any feedback is appreciated!

It takes a few dozen to start to get comfortable.

Just make sure you're setting yourself up for success on your first DL. Good positioning, and give the muscle relaxant enough time to work.

 

[Doctor4Life1769]

it was weird for me.

i nailed my few intubation opportunities as an intern and even as a CA-1 off the bat for 2-3 months, then for 1-2 months it seemed like i was goosing every other one. now, im intubating flawlessly without stylettes and moving up to advanced airway techniques electively when i can. eventually you get the hang of it, dont worry bout it.

 

[countingdays]

Hi,
I'm an intern who will be starting my CA1 year in July. I'm currently doing a month-long anesthesia elective, and find that DL intubation is still somewhat difficult for me. Obviously I don't have near the experience compared to seasoned attendings or even residents, but I feel somewhat discouraged because I don't know if other anesthesiology residents- when they were med students or even interns- felt like DL intubation was a breeze. Is it normal to still struggle a bit until you REALLY start to do intubations every day? Did anyone else feel this way? I just hope I'm not a total spaz and way behind my fellow CA1's when we start in July. Any feedback is appreciated!

Don't try to get a better view by lifting harder.
Get a better view by positioning the blade better.
Don't try to look while you advance the blade.
Put it in, then look.

 

[DreamMachine]

I tend to use a smaller size than recommended. Less traumatic and I haven't had a problem ventilating. Sometimes you got to bend the stylet more to get a better angle. If I do this, I often take the stylet out early before I turn and advance. Sometimes not. Depends. Foremost, I don't want to rip something airway. If you have trouble turning, just intubate the trachea and guide the bronchial side with the fiberoptic. If you have trouble getting it in, use a cook catheter. If you have trouble with the cook catheter, use a bougie and a regular tube, then put the cook catheter down the regular tube. Worst case, main stem a regular tube and tell the surgeon you did that because it was hard.

What is the main problem you run into?

 

[IveGotTwins]

I think in this case DL means Direct Laryngoscopy rather than Double Lumen.

 

[Dejavu]

Don't try to get a better view by lifting harder.
Get a better view by positioning the blade better.
Don't try to look while you advance the blade.
Put it in, then look.

I would propose a different approach.

Put the blade in just far enough to see the epiglottis. Once you see that, you know were everything else has to be. Then advance the blade slowly toward the target. And don't hurry. If you pre-oxygenated/de-nitrogenated, you should have several minutes before you run out of O2 molecules. If you actually time it, most intubations, even tough ones, only take about 45 seconds or so. It just can seem like a lifetime.

Especially with a Miller (which we in the Midwest use a lot of), the most common mistake of a learner is going too deep before looking and never being able to find anything but the esophagus down there.

 

[pgg]

I tend to use a smaller size than recommended. Less traumatic and I haven't had a problem ventilating.

This is a good point. Less sore throat complaints after too. For cases I plan to extubate at the end I usually put a 6.5 tube in women (6.0 if they're small) and 7.0 in men. If I know someone's going to be intubated for a day+ I'll put in a big tube to facilitate bronchs etc.

There's no reason to jam an 8.0 in every guy because he's a guy.

 

[countingdays]

I would propose a different approach.

Put the blade in just far enough to see the epiglottis. Once you see that, you know were everything else has to be. Then advance the blade slowly toward the target. And don't hurry. If you pre-oxygenated/de-nitrogenated, you should have several minutes before you run out of O2 molecules. If you actually time it, most intubations, even tough ones, only take about 45 seconds or so. It just can seem like a lifetime.

Especially with a Miller (which we in the Midwest use a lot of), the most common mistake of a learner is going too deep before looking and never being able to find anything but the esophagus down there.

Maybe. When I started with the MAC I think I'd just push the tongue deeper by trying to look too early and advancing the blade while looking.
I think you are better off putting the blade deeper and backing out until you have a view or the epiglottis falls. Ideally you just put it in deep, look, and have a grade 1 view.

I guess it depends on what you do now. If starting shallow and advancing isn't working, try placing it deeper initially. If you are putting it deep now and getting lost, try just finding epiglottis like Dejavu recommended.

Also, extend the head/neck. It's better than sniffing position.

 

[gasattack3]

It takes a few dozen to start to get comfortable.

Just make sure you're setting yourself up for success on your first DL. Good positioning, and give the muscle relaxant enough time to work.

Yep, positioning in advance is key. This takes time getting to know the types of patients which will benefit from a little wedge versus none, a little back up etc.

I routinely set the timer when giving rocuronium after realizing that we ROUTINELY overestimate the time until DL. Now, I like to wait a good 1.5 to 2 minutes. They should be very relaxed at this point. But often, at a dose of 0.7mg/kg (or the standard 50 mg dose we typically use) I've noticed that we're trying to tube after only 30-45 seconds when not looking at a clock. But, when you're ventilating for 2 minutes, you see quickly just how much time that really is....lol

 

[Yo GabbaPentin]

So here is the ultimate secret my friend....

Combitube. Done.

 

[bkell101]

Yep, positioning in advance is key. This takes time getting to know the types of patients which will benefit from a little wedge versus none, a little back up etc.

Im an intern and experimenting with positioning during all my ICU intubations. I have a ton of questions....

1. Everybody including attendings sticks a pillow under the shoulder blades, which seems like it creates a good deal of extension at the OA but isn't really sniffing position with flexing at the lower cervicals.
-why are they doing is?
-which pt's might this work best in?

2. I did it their way for a little early in the year and now that they are more comfortable wih me, I've been trying to get patients in a nice sniffing position and people are looking at me like I have eight heads. I've even had a nurse pull out my towels, roll them up, shove them under the pt's back, and say there ya go just wanted to help u a little. Either I am confused or they are confused.
- I doubt what I am doing with the towels and pillow is the best way to create sniffing position, how do you guys/gals achieve this in squishy ICU beds?

3.Can you elaborate some on the above post? What does a little wedge mean? What does a little back up mean? How do you evaluate which pt's will benefit from specific positionings?

Thanks!

 

[cincincyreds]

Hi,
I'm an intern who will be starting my CA1 year in July. I'm currently doing a month-long anesthesia elective, and find that DL intubation is still somewhat difficult for me. Obviously I don't have near the experience compared to seasoned attendings or even residents, but I feel somewhat discouraged because I don't know if other anesthesiology residents- when they were med students or even interns- felt like DL intubation was a breeze. Is it normal to still struggle a bit until you REALLY start to do intubations every day? Did anyone else feel this way? I just hope I'm not a total spaz and way behind my fellow CA1's when we start in July. Any feedback is appreciated!

I was pretty comfortable as a third year medical student since I would go from room to room doing all the intubations. I could get like 20-30 in one day.

The first thing you need to learn is what the structures look like. Ask an attending to use a glidescope so you can visualize what to look for. Then look at youtube for glidescope intubations.

Next do your own dl, put the blade in without touching the teeth. Find the epiglottis. If you see it, you know you need to go in a little bit further, this is with a Mac 3. Now when the epiglottis moves out of your way because you are in the voleculla, you should see the cords. If you don't, it just means the cords may be a little anterior. Just ask an assistant to press down on the neck over the larynx and the cords should come into view. You may also just only see the arytenoids which are the bottom part of the vocal cords.

Lastly, you need to remember positioning is important. You need the sniffing position, imagine it if you smell the fresh air in the morning. So, you may actually need someone to lift the head off of the table at the same time giving you cricoid pressure. This should help.

 

[countingdays]

Almost every time I intubate after a crna doesn't get it, they had sniffling position and I switch to extension. I don't know why people continue to talk up the sniffing position. I think it makes matters worse.

 

[Impromptu]

I am now on my 6th month of pediatric anesthesia and I have re-learned to respect the pediatric airway. I don't want to consider anything routine. Intensity and focus every time.

 

[Doctor4Life1769]

I am now on my 6th month of pediatric anesthesia and I have re-learned to respect the pediatric airway. I don't want to consider anything routine. Intensity and focus every time.

are you a pedi fellow or you're doing 6 months as a resident?

my program allows us a max of 5. one in CA-1, one in CA-2, and up to 3 in CA-3.

 

[rsgillmd]

Almost every time I intubate after a crna doesn't get it, they had sniffling position and I switch to extension. I don't know why people continue to talk up the sniffing position. I think it makes matters worse.

Go with what works for you. My experience has been the opposite.

I never truly understood what people describe as sniffing position, so I just try to put the corner of the ear at the level of the sternal notch when I extend the patient's head. A roll between the shoulders and then blankets (not the flexible pillows) under the head to create this.

Take a look at the Troop pillow and other similar commercial products -- they basically do the same thing.

 

[Arch Guillotti]

I am now on my 6th month of pediatric anesthesia and I have re-learned to respect the pediatric airway. I don't want to consider anything routine. Intensity and focus every time.

What happened? Intubation, ventilation, or laryngospasm?

I have never had a pediatric patient I couldn't intubate or ventilate; although I do not staff cases with obvious difficult airways.

 

[Bostonredsox]

Hi,
I'm an intern who will be starting my CA1 year in July. I'm currently doing a month-long anesthesia elective, and find that DL intubation is still somewhat difficult for me. Obviously I don't have near the experience compared to seasoned attendings or even residents, but I feel somewhat discouraged because I don't know if other anesthesiology residents- when they were med students or even interns- felt like DL intubation was a breeze. Is it normal to still struggle a bit until you REALLY start to do intubations every day? Did anyone else feel this way? I just hope I'm not a total spaz and way behind my fellow CA1's when we start in July. Any feedback is appreciated!

It is like every other procedure, success/failure rates are directly proportional to experience. I have found that residents who are very good with airways early on had great exposure as a med student. Now I am IM/CC so I have never had a controlled airway in an OR and my #s are probably hundreds less than the equivalent gas resident, but I do pretty well i think and I am becoming far more confortable with advanced airway techniques and so forth. My first tube I will enver forget. 4th year med student, my good buddy the ED attending. Took me up to a quickly declining but still awake big italian dude in Endo. Handed me a Mac and said 'here you go you get one shot. Couldnt get it. Was crushed. No less than 24 hours later similar situation yet it was a decompensationg Post CABG day 2 guy. Hands me tube and says one shot. Slammed that bad boy in. Felt vindicated. From that day forth I realised it is just practice. Learn what feels right and works for you. If some jerk is telling you 'you need to use miller blades they are superior but your comfortable with a mac, tell them to **** off and use a mac. Dont attempt something you are not comfortable with. Another big thing I have learned is know what to do if you get into trouble, and know when to call for help. Now as a PGY 2 I have 60 airways or so last I checked, again, chump change to the gas guys, but if i think I might get into trouble, I call for help early and say hey can you stand here in case I get into trouble. No ego issues. People die to big egos. But every tube you put in your confidence goes up and you get more comfortable with what you are doing, but do notlose respect for the airway. Today I had an intern electively intubate a severe septic that was starting to go down hill. Rapid sequenced with etom/succ and once she was paralyzed, he looked quick and said I dont see anything and tried to hand me the blade. he was scared I could tell. handed him the blade back, calm down, insert the blade, position the head and talk. Tell me what you see. Walked him right through it. I am sure he will be a little bit better the next time. And so on and so forth.
Bottom line, do what is comfortable for you. And to answer your first question about when should you feel comfortable, I had a code first weekend in MICU, first month of intern year. Senior was in code. stepdown nurse calls panicking we need help fast. ran over. Took a deep breath, RSId him and through an 8.0 in that fat bastard. Have never looked back since. it is all about your experience.
Hope that helps.

 

[Idiopathic]

that might be the longest post ever on this subforum. essentially, tl;dr

to reference an earlier post, im not sure that most people really understand sniffing position. there is head extension suprimposed on neck flexion. if you try to do one or the other, you will be successful frequently, but will get burned when it matters, as in you will hyperextend the neck when you think you dont need a pillow under the head. remember, you are trying to position the oral axis as close to 90 degrees from the pharyngeal/laryngeal aperture as you can...sometimes you can do this with just brute force/arm strength, but when it doesnt work, it doesnt work spectacularly

 

[bkell101]

Almost every time I intubate after a crna doesn't get it, they had sniffling position and I switch to extension. I don't know why people continue to talk up the sniffing position. I think it makes matters worse.

Can you explain this to me?

 

[WholeLottaGame7]

that might be the longest post ever on this subforum. essentially, tl;dr

It DID involve RSI'ing a pt with severe sepsis using etomidate, so you missed out on that.

 

[Bostonredsox]

It DID involve RSI'ing a pt with severe sepsis using etomidate, so you missed out on that.

I'm aware of the data, read my post on the new meta analysis for etomidate use in severe sepsis in the critical care forum. While I personally agree with the etomidate adrenal insufficiency idea and I do think it probably affects mortality, I use only what I have at my disposal. The pt in that example had a map of 45 on 2 pressors, we don't have ketamine in our icu, and she laughed at 5 of versed. That left amidate to induce with.

 

[Idiopathic]

i dont have a problem with it. the data is all over the place.

from this months Crit Care Med. retrospective, yes, but 2 thousand patients

http://www.ncbi.nlm.nih.gov/pubmed/23318491

CONCLUSION:: In a mixed-diagnosis group of critically ill patients with sepsis, severe sepsis, and septic shock, single-dose etomidate administration for intubation in the ICU was not associated with higher mortality or other adverse clinical outcomes.

 

[WholeLottaGame7]

I'm aware of the data, read my post on the new meta analysis for etomidate use in severe sepsis in the critical care forum. While I personally agree with the etomidate adrenal insufficiency idea and I do think it probably affects mortality, I use only what I have at my disposal. The pt in that example had a map of 45 on 2 pressors, we don't have ketamine in our icu, and she laughed at 5 of versed. That left amidate to induce with.

The back story didn't come out at first. You gotta do what you gotta do.

 

[Impromptu]

What happened? Intubation, ventilation, or laryngospasm?

I have never had a pediatric patient I couldn't intubate or ventilate; although I do not staff cases with obvious difficult airways.

You know that quiet sound that is made when those little vocal cords slam shut post extubation in the ENT room? I hate it. The airway was being handled by a rotating Peds ER fellow (though may have happened to me, too). Knowing when to jump in, how to ventilate better, if to give succinylcholine and atropine, and manage the situation were key. Time seems to go much slower when listening to your pulse ox in that situation. But, after a short delay we were back on our way to the PACU.

I am glad to have had a few experiences like that heading out to become an attending.

I have found that pediatric intubations and mask ventilations are usually pretty easy. But they desat so fast, and we must always be vigilant for laryngospasm and breath holding. Turn the room over? Not till the kid is breathing.

I am not sure why we have 5-6 months of peds in my residency. I have suspicions, but would rather not post them on an open forum.

We just intubated a trisomy 18 infant. Parents later told me it took the last hospital's PICU 10 tries to get it in. We got it on the first try, but I won't rest on my laurels.

 

[Shadowboricua]

Hi,
I'm an intern who will be starting my CA1 year in July. I'm currently doing a month-long anesthesia elective, and find that DL intubation is still somewhat difficult for me. Obviously I don't have near the experience compared to seasoned attendings or even residents, but I feel somewhat discouraged because I don't know if other anesthesiology residents- when they were med students or even interns- felt like DL intubation was a breeze. Is it normal to still struggle a bit until you REALLY start to do intubations every day? Did anyone else feel this way? I just hope I'm not a total spaz and way behind my fellow CA1's when we start in July. Any feedback is appreciated!

As a medical student I did an Anesthesiology Sub-I and I blew all my DLs; thankfully attendings were nice enough to not base their letters of recommendation on my ability to to DL ;-).

Then I spend my whole internship (PGY-1) without touching a blade.

As a CA-1 (currently); I felt comfortable DL'ing from day 1 in the OR... we did have a little simulation before starting in the OR but I think what helped me was the fact that I was not really trying to impress anyone anymore; I just knew I had to do it right. Also, I was also lucky to have a great attending that was patient and gave me great tips during those first few times. Don't worry; you'll get there. Some people will be more comfortable, and some won't. If you are a total spaz; you won't be the only one. Just remember; MANUAL MASK VENTILATION is the technique you should really worry about mastering.

 

[Bostonredsox]

i dont have a problem with it. the data is all over the place.

from this months Crit Care Med. retrospective, yes, but 2 thousand patients

Agreed. It is hard to interpret. The Randomized trials did not show mortality changes. That is why I stil routinly have been using it in my septics. then this retrospective meta analysis comes out....what to make of it...not sure. In any rate given shortages I am still going to be using alot of amidate. it makes me feel better though knowing that I am atleast attempting to follow along with what the data is recommending.