[Athlein1]

Hey all,
Anyone have any tips for using a Miller? I started clinicals using the MAC, and now that my intubations with it are pretty consistent, I decided to move on to the Miller. I'm striking out...
Any pearls would be appreciated!

[WntrMute2]

Originally Posted by Athlein1

Hey all,
Anyone have any tips for using a Miller? I started clinicals using the MAC, and now that my intubations with it are pretty consistent, I decided to move on to the Miller. I'm striking out...
Any pearls would be appreciated!

The miller is my blade of choice since it is what I started with. The trick to it is to displace the tongue to the left as soon as possible. I start with the blade/handle rotated 90 degrees to the left so the blade surface enters the mouth alongside the tongue, as I move deeper into the oral cavity, the blade is displacing the tonge as I move towards the centerline. As this is occuring, I am rotating the blade/hadle back to the normal position and as the epiglottis comes into view, the blade is midline and correctly oriented. Slip the blade under the epiglottis and lift. Things to watch out for: Tongue MUST be moved all the way over to the left. Epiglottis may slip off of the tip or you can enter too deep and be looking down the esophagus, slowly pull back and the cords will appear. Insuring a good sniff position of 10 cm. will usually improve laryngoscopy in general. Lifting the head vertically if the view is not good is also helpful. I lke the blade as I like to believe there is a little more finesse involved. I do work with the mac every couple of days to remain adequate with both.

[athomas91]

the CRNA i am primarily with started me on a 2 miller - i love it...when i am with others - they make me use the mac...it is ok but my success rate is nearly 100% w/ the miller -

my biggest problem is getting the darn mouth open...i hate that part - but am getting a little better..

the previous post was an excellent instruction - i will just add that for me the key lies in going steady and finding the structures...visualizing the epiglottis, gently dipping below it and lifting -

i am sure you will become very able soon!!! you can give me mac hints if you like!!

[Athlein1]

Okay, so it's been a couple of weeks. I've been successful with the Miller about 50% of the time now. It was hard for me to control the tongue for awhile - as soon as I thought I had it firmly secured with the blade...plop, off it went to the side. So, back to the start I went. One thing I realized is that the Miller requires a LOT of lift. You must lift up and away toward the wall with effort. Sure like the ease of insertion of the narrower blade as compared to a MAC. Also, it seems the MIL2 is easier to work with than the MIL3. The MIL3 is just so big. Slide it in just a bit and you are already in the esophagus!
So, I guess I am a MAC fan. But, as one preceptor told me, the trick is to be good at whatever you have in the drawer. Then, he showed me a Wisconsin blade. Now, THAT is a big old blade...

[gaspassah]

i was instructed that you have to sort of "fish" the tip of the miller once you get the epiglottis up, sorta work it around a little, also it helps alot more if you use the right hand to manipulate the trachea as you "fish". i was having the same problem, so i've started trying to use the miller a little more also.
d

[yoga crna]

I use a MAC computer and a Miller blade.

The other suggestions are excellent and I would like to add a few more. Make sure the head is positioned properly, open the mouth gently with the blade--you shouldn't have to pry it open (muscle relaxation!!), once you have lifted the epiglottis, advance the blade about a centimeter--opens up the sub-epiglottic area for easier insertion of the tube. Don't try to advance the tube through the opening of the blade--you will lose your visualization.

I have used a Miller 2 almost exclusively for 44 years. It can be used to intubate children through old-age. Every once in awhie, I use a MAC blade, just to do something different. But my Miller is always ready to go. Currently in my practice, I use mostly nasal intubations for face and neck lifts. The Miller works well for those cases as well.

Yoga

[Passin' Gas]

Quote: Athlein1 "But, as one preceptor told me, the trick is to be good at whatever you have in the drawer...."

There's a lot of truth in that statement. Responding to a code on the gyn-onc floor, GI lab, hemodialysis unit...wherever.... and the only blade with a viable light is Miller 3. It may not be your best blade but you CAN use it to expose cords and stick in an ETT in the proper orifice.

PG