I'm an SRNA with a little more than a year left in school, and I'm here seeking some advice with intubation technique. I started out, as did the majority of my class, using the Mac blade for intubations. Most preceptors advised me to become competent with the Mac blade, and then transition to the Miller blade. At this point I am pretty comfortable with the Mac blade. The majority of intubations go smoothly, however, it seems like every 25th case or so I run in to the same problem. Its always the same problem, and I'm not sure how to fix it.
The problem is that as I enter the posterior oropharynx and lift up, I will have a great view of the entire epiglottis, completely covering the cords. My first inclination is to go deeper in to the vallecula and lift again, but for some reason this often does not work. I then apply cricoid pressure, and at that point I might have a grade III view, of just the most posterior aspect of the aretynoids. I can maybe sneak an Eshmann through and save the intubation, but sometimes not. A lot of times when this happens, it is not on patients who appear to be anterior, or whom I would expect to have difficulty with their airway. I have yet to find a solution for the scenario of blade in vallecula, epiglottis completely obstructing view. This happened to me yesterday on an African American 6', 240lbs patient, with a mallampati 2. I was using a Mac 4, and repositioned the blade as deep as I could once I saw the epiglottis was obstructing my view. I'm just not sure what else to do besides reposition the blade, and/or use cricoid pressure.
The thought that keeps coming in to my head when this happens is: "I wish I could directly lift the epiglottis." This leads me to think that perhaps I would avoid this situation with a Miller blade. Has anyone had a similar experience? Is this one of the limitations of the Mac blade, or is it just a limitation of the person wielding it? Should I try to transition to the Miller blade to avoid this scenario? Any tips appreciated.
Jan 4, '13
Individuals who are "mac Blade users" always find that they have to abandon their blade of choice in certain patients and grab the miller blade. "Miller blade users" NEVER find they have to abandon their preferred instrument in favor of a mac. I am a 'miller man' in the interest of full disclosure, so much so that it is beyond me why anyone ever uses a mac blade.
I can still say objectively that a miller blade is a MUST when you have any of these situations: limited mouth opening, limited neck extension, small mouths relative to head size, overbites, poor Mallampati score, poor dentition with significant danger of knocking a tooth out on laryngoscopy. And "using a mac like a miller" to lift the epiglottis certainly is a valid technique but it will not change the result in most cases.
Your solution? Use a miller blade....some of us use it 100% of the time.
Jan 12, '13
Not a CRNA, in a BSN program but have been a paramedic for 13 years and probably done around 150-200 intubations in that time. You probably already have much more airway experience than I do, and I realize that intubating in the field and the OR are completely different, but but our rule in the field when we encounter challenging airways is to move on to a different blade if the first view / attempt is unsuccessful. Use a different blade, or use the bougie, or use the King Vision. I've had a few patients over the years where I just could not visualize the cords with a mac, but as soon as I switched the Miller it became easier. It seems to me that anterior airways are often times better viewed with a mac, but like I said, not nearly as much intubating experience as most on this board. Cheers.
Feb 21, '13
I haven't met much I can't tube with a Miller 3. It is my exclusive choice.
Mar 1, '13
Miller 2 user, which can be used as a Mac, if you need to. My best advise for intubation success is head position. Raise the head to snifting position -- look it up, there are some excellent illustrations out there. If you hyperestend the head too much, the anatomy is compromised and intubation is more difficult.
It is worth another discuss/argument, but I always use a stylette. The reason being--I work alone and do not need to take the extra time to instruct a non-anesthesia helper how to put a stylette in a tube. When you work alone, you learn to do everything without much assistance and to have everything ready and closeby.
Mar 25, '13
I know the old saying "if you are going to change from a Mac to a Miller with a difficult airway then why not just juse the miller exclusively"....because the MAC is just ******* awesome. Everything about it is easy. Give me a mac 3 or 4 and I'll intubate 99.9% of America.
Mar 27, '13
Do don't have much experience, do you?