Clinical question about laryngoscopy

WntrMute2 · Jun 6, 2004

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?

I experience Grade 1 to 2 views almost every time. Only once in the past few months have I not been able to visualize everything or at least 1/2 of the cords. The CRNA who told you that is blowing smoke. Try improving your positioning. True sniffing position (10 cm elevation of the occiput) will really improve you views. Don't let people compromise that position with pillows, placing the head flat, etc.

Tenesma · Jun 6, 2004

first of all there is no relationship between ASA status and airway grade of view!!!! I have had ASA I pts that were can't ventilated/can't intubate (very bad!)

I see cords almost all the time - i would say that i do so-called blind intubations maybe 2 times a month (pretty uncommon).

My recommendation is to reposition the head, change blades... etc... So far a Miller 3 is my lucky blade (and the perfect thing for codes on the floors).

gaspassah · Jun 6, 2004

are you using the same blade each time your having difficulty or are you switching blades and still having difficulty seeing?

someone taught me to "fish" with the tip of a miller when i was having problems with the miller and to use the right hand to manipulate the trachea at the same time. this tech helped me alot.

there were a couple i had recently that were anterior enough that i only saw arytenoids and shot above them and was lucky enough to get them.

i dont think it's your technique, more likely just a run of bad luck, difficult airways or both.

d

Athlein1 · Jun 6, 2004

Thanks for the replies...

Try improving your positioning. True sniffing position (10 cm elevation of the occiput) will really improve you views. Don't let people compromise that position with pillows, placing the head flat, etc.

WntrMute, your point about position is an excellent one. Agree completely. At this particular clinical site, a couple of the preceptors want me to do things their way, i.e. use a pillow for positioning, don't use a foam headrest, no ramping with blankets, Miller vs MAC, etc. Sometimes, it's just easier to go with the flow at clinical - you know what I mean.

first of all there is no relationship between ASA status and airway grade of view!!!! I have had ASA I pts that were can't ventilated/can't intubate (very bad!)

Dang, Tenesma, you must think I am a real dumbs&*t. Allow me to clarify. My correlation with missing intubations and ASA levels has nothing to do with airway class and everything to do with cardiorespiratory reserve. I am not going to subject an old COPDer or s/p CABG patient who can't even walk to his mailbox (how many mets is that?!) to protracted or multiply-repeated laryngoscopy. If I can't see what I need to see in short order with repositioning, cricoid pressure, or tracheal manipulation, then I am out of there and my preceptor can give it a go.

Hi D, how are things?! Liked your article in the newsletter! I'm thinking part of it might be that I am a MAC lover trying to use the Miller more often. One of my preceptors noted that if the Miller 3 is the blade you would pick in a difficult airway scenario, why not use it all the time? Interesting point. My goal is to try to get proficient with whatever blade is in the box, keep their teeth absolutely untouched, and not nick lips. What do you mean by "fishing"?

gaspassah · Jun 6, 2004

in "fishing" i mean that after you lift the epiglottis with the tip of the blade and dont see anything you move the tip left and right a little to reposition the tip of the blade in a different area while still maintaining control of the epiglottis. this movement will displace tissue that may not have been moved during initial laryngoscopy. so it's like multiple attempts in one pass.

does this make sense? sometimes i ramble.

d

jwk · Jun 6, 2004

What's the best way to intubate? (after learning the basics of course)

YOUR WAY!!!

Mac 3, Miller 2, light wand, whatever.

If the tube goes in the right spot on the first attempt the vast majority of the time without damaging the teeth, lips, or airway, you're doing it the right way.

Athlein1 · Jun 6, 2004

Gotcha, D. Haven't done that yet with the Miller. Will give it a try!

JWK, still working on that "vast majority" part!

georgia_aa · Jun 6, 2004

The observation that if the Miller 3 is the blade of choice in difficult situations why not start out with it is a great one and one that was pointed out to me early in my career. I have used the Miller 3 on 98% of my intubations for about the last 10 years with great success. The only exceptions are for double lumen tubes as the MAC clearly gives you more room to manipulate the tube and keep from tearing the tracheal cuff on the teeth.

The Miller blade is a more difficult blade to master but once you do it renders the MAC blade totally obsolete in my opinion. My technique is to place the patients head on 1 sheet and go right down the middle of the oral cavity with the blade. Sometimes I use my right hand and reach around to manipulate the trachea as I lift the blade as another poster suggested - it's a great technique. As you're learning the blade start out with edentulous patients so you don't have to worry about damage to their dentition.

I see the entire cords the vast majority of the time and I at least see some recognizable structure on the really hard ones.

Qwiigley, BSN, MSN, DNP, RN, CRNA · Jun 6, 2004

Position, position, position!

RAMP, RAMP, RAMP!

There is no room for pride and cowboys in the OR. People's bodies and lives are the ONLY focus.

You will get more comfortable with intubations with time. Not everyone gets all of them. Go back to the basics; it will always do you well.

Preceptors, although have the best intentions, can sometimes make things worse. Do what you are doing, go with the flow on the first intubation, and on the next, when you have had time to feel the preceptor out, tell them that you would like to do the next intubation with a "different" prep. Sometimes you are not just selling yourself.....

Good Luck!

sonessrna · Jun 13, 2004

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.

Brenna's Dad · Jun 13, 2004

Ah, a topic dear to all our hearts.

Interestingly enough, I've had a few people tell me the same thing, ie. that they very really see the cords.

I very rarely do not see them and then have always been able to see the arytenoids. I find the most difficult intubations to be RSI and it's because of the cricoid pressure. At times this causes so much compression that the glottis looks like the esophagus, or you just dont see anything. When this happens I ask the cricoid pressure person (most often a Doc) to let up a little until I get a view.

I agree with the RAMPING advice. I'm always amazed at just how much positioning improves the view. These days I'm using a folded bath blanket instead of a pillow and find it improves my sniffing position immensely.