Clinical question about laryngoscopy

[Athlein1]

Question for you SRNAs in clinical and practicing anesthetists:

How often do you get a Grade I or Grade II view?

I have started missing an intubation or two per week (probably because I am moving beyond the healthy ASA I/II). Was working with a CRNA last week, trying to explain what I saw, and she told me that she only sees the cords once or twice per week! Usually, she glimpses arytenoids with the MAC or displaces the epiglottis with the Miller and aims the tube right above.

This was a revelation to me. I was taught to look for the vocal cords with direct visualization of the glottic opening. Blind passes were attempted, but usually after changing blades, repositioning, etc. In other words, not a common practice.

What do you think?

[kestrel1121]

Hey Brenna's Dad-I pM'd you!

[jwk]

I'm not an expert in intubations...but I have only had 1 blind intubation since I started intubating and I did an esophageal intubation with that also my only esophageal intubation yet so far.. I think you should always be able to see cords or be using something to augment your intubation...at least that is what we are being taught in school. I have been using a MAC 3..I'm going to attempt the MIller blade this week.

You'll be an expert by the time you're done with school, don't worry. I'd guess I see cords maybe 80% of the time (?), and most of the time if I don't see them, I have enough curve in the tube to "scoop" it in on the first attempt anyway. If I'm pretty sure I can get it in with enough curve, I'll add a stylet on the 2nd try. 3rd attempts now we either go with a lighted stylet or to an LMA. Continued repeated attempts will lead you down a slippery slope, so unless you can't ventilate the patient, I'd pop in an LMA and re-think, or awaken the patient.

The slickest thing I've seen recently is a device called a GlideScope. It's basically a curved blade with a TV camera at the distal end of the blade. You watch the view on the TV screen, and watch the tube go in. There's no need for a sniffing position, because you're not having to bring all the airway structures into a straight-line view. Get a rep to bring one in for your class to try out if you haven't seen one. You'll be impressed.

Anyone who claims they never get an esophageal intubation, ever, is fudging little to say the least, even an experienced anesthetist. It's not a sin to put the tube in the wrong spot - the sin is in not immediately recognizing it and putting it in the right spot.

[gaspassah]

the sin is in not immediately recognizing it and putting it in the right spot.

on this i think we all agree.

well done.

d

[J.L.Seagal]

How many attempts would you make at an intubation using a MAC or Miller blade before going to other interventions in order to establish a definitive airway? Is there a specific protocol for this or does it generally depend on the one doing the case?

[Athlein1]

Is there a specific protocol for this or does it generally depend on the one doing the case?

Seems to me that it depends on who you are working with in clinical that day. There are some preceptors that will let you reposition the head/pillow/blade a couple of times, then let you change blades. There are other preceptors that will take over in 20 seconds if that tube is not in.

Patient condition also plays a factor. Preceptors are less indulgent of repeated attempts with sicker, obese, or pediatric patients!