Difficulty intubating...

Medic09, BSN, RN, EMT-P · Jun 11, 2010

Hey Sweettooth,

Remember that technique is everything. Almost. If you keep getting the same view, you need to change something in HOW you are creating that view.

Get scheduled for OR time. If you have a good doc, a bit of good coaching will be worth a thousand words.

Review all the factors that influence your view. Start with head position. Don't forget that a maneuver like BURP is very useful for improving view. What about your left hand technique. Are you cranking up towards the ceiling (BAD), or lifting up, and out over the feet towards the high corner of the wall and ceiling? You get the idea. Get a good text to review and remind you, like Walls - Manual of Emergency Airway Management, or Levitan - Airway Cam book.

And don't forget to always have your backups ready and next to you, and go to one sooner rather than later. A failed intubation is no shame; but an unventilated patient is dead.

Good luck!

guest416560 · Jun 11, 2010

Once the blade is in make sure that tongue is really out of the way. That seems to be a major problem for beginners. After that lift up.....when I say that....lift their head off of the bed if it helps you see the cords. This works 97% of the time in my experience.

Esme12, ASN, BSN, RN · Jun 11, 2010

Intubation int he OR is different than the field. The setting is ALWAYS less that perfect. I had always prefered a straignt blade go in and pull back(out) slowly and ..... bingo! Also try cricoid pressure, have some one apply pressure that usually helps. Be patient...like anything else it is an acquired skill.

GilaRRT · Jun 11, 2010

Hey Sweettooth,
Remember that technique is everything. Almost. If you keep getting the same view, you need to change something in HOW you are creating that view.
Get scheduled for OR time. If you have a good doc, a bit of good coaching will be worth a thousand words.
Review all the factors that influence your view. Start with head position. Don't forget that a maneuver like BURP is very useful for improving view. What about your left hand technique. Are you cranking up towards the ceiling (BAD), or lifting up, and out over the feet towards the high corner of the wall and ceiling? You get the idea. Get a good text to review and remind you, like Walls - Manual of Emergency Airway Management, or Levitan - Airway Cam book.
And don't forget to always have your backups ready and next to you, and go to one sooner rather than later. A failed intubation is no shame; but an unventilated patient is dead.
Good luck!

Great advice.

Intubation int he OR is different than the field. The setting is ALWAYS less that perfect. I had always prefered a straignt blade go in and pull back(out) slowly and ..... bingo! Also try cricoid pressure, have some one apply pressure that usually helps. Be patient...like anything else it is an acquired skill.

This is actually a very common misconception. Cricoid pressure is theoretically applied to prevent passive regurgitation. In fact, cricoid pressure may actually worsen the glottic view. A technique known as ELM or sometimes the BURP maneuver involves manipulating the thyroid cartilage and may improve the glottic view. Often, many providers mistake the thyroid cartilage for the cricoid cartilage and inadvertently perform ELM when they think they are performing cricoid pressure however.

medicrn13 · Jun 12, 2010

I had many problems with field intubation, poor view etc. Then I started placing a rolled towel or a pillow underneath my patient's shoulders, view improved dramatically and I've had no problem since.

AnnieOaklyRN, BSN, RN, EMT-P · Jun 13, 2010

I tried the pillow under the head thing and that doesnt do much for me, plus if I have a trauma patient I won't be able to rely on that.

I feel like I am having trouble getting control of the epiglotis, like its still flapping into my view, but when I try using a miller instead of a mac to get better control of the epiglotis I cannot see anything so that doesn't help. I was thinking of maybe switching to a mac 4 and using it like a miller if need be???

All, but one of my patients, that I have intubated in the last few months have been alive, but severely obtunded so I am not sure if that is why I am having trouble pulling their epiglotis out of the way. I feel like I am pulling up and towards where the ceiling and wall meet so to speak, but still that darn epiglotis gets in my way. In my state we cannot use RSI or give even sedation medication to facilitate intubations.

I have also talked about the company allowing us to do OR time to keep up on skills etc which would probably help me since my main problem is I just hadn't intubated in about 3 years until recently; however no one seems to open to it, which stinks.

Anyone have additional suggestions given my additional information about my troubles? Thanks

Sweetooth

GilaRRT · Jun 13, 2010

So, you have not intubated in a three years, you have nit been through a recent course, you have no recent mannequin time to practice technique, and your employer refuses to set up theatre time in spite of you voicing intubation concerns?

On a side note: ELM and BURP are not really the same thing. Sorry if I confused anybody. There is also a growing body of evidence that does not support BURP.

AnnieOaklyRN, BSN, RN, EMT-P · Jun 13, 2010

So, you have not intubated in a three years, you have nit been through a recent course, you have no recent mannequin time to practice technique, and your employer refuses to set up theatre time in spite of you voicing intubation concerns?
On a side note: ELM and BURP are not really the same thing. Sorry if I confused anybody. There is also a growing body of evidence that does not support BURP.

You got it Gla! The problem with EMS is that despite the fact that depending on your service area you may not do that many intubations per a month or year, this does not get addressed by having paramedics do OR time to keep up on the skill... Its quite unfortunate and I do not quite understand why that is. I would immagine it might be a problem for hospitals liability wise, but hospitals allow students to intubate, so why not paramedics who just need to keep up on the skill!

Sweetooth

loveanesthesia · Jun 14, 2010

When using the MAC blade, the tip of the blade needs to be under the epiglottis. If you don't advance the blade enough, you can't lift the epiglottis out of the way. If you advance the blade too much, then you push the epiglottis forward and down over the glottis. Next time advance the tip of the blade slowly, lifting the head off the pillow the entire time, once you get a full view stop. You can lift the head with your right hand while holding the blade with your left. You need to watch for landmarks the entire time you advance the blade, rather than putting the blade in and then looking to see if you can find anything.

Another common error is confusing hyperextending the neck with the sniffing position. Putting the head in extreme extension will make it difficult to intubate the easiest person. Sniffing position is raising the head of the adult 10 cm higher than the shoulders. Some people, especially older people need their head raised more than that. Once you get your view with raising the head with your right hand, ask someone else to hold the head and you can pass the ET.

ssrhythm · Jun 18, 2010

Hey man, I feel for you and understand exactly where you are. I am an RT, and from 2001-2005 I worked two hospitals where we were the primary intubators. They put us through many OR days, and we intubated 98% of the patients that got intubated. After a couple of weeks of difficulty, it got better and better. I became one of the night shift supervisors at the first hospital, and out of my crew, only one other RT had any desire to intubate, but he would always back away and let me do it if he had a choice. In those years, I intubated often, and intubated people on the floor, an obese pt with the bed stuck in trendelenburg, etc., and became very confident.

During my BSN work and my critical care RN work prior to CRNA school, I did not intubate for five years.

When I got into the OR during our first few weeks of clinical, it was as if I'd never held a flipping laryngoscope in my life! I never saw cords on my first four attempts in a very controlled environment, and it was very frustrating. I finally had an easy intubation, and from there out, things have gotten much better. That said, I have continued to experience poorer views at a greater rate than I ever remembered when I was working as an RT. My explanation for this is that I plain didn't remember just how difficult DL and intubation can be. Also, after all the knowledge about the airway and techniques is in your head, it is a SKILL. Any skill becomes better and thus more successful with repetition and experience and diminishes without it. Add to that the conditions you are operating in, and you truly have a situation that will lend to trying intubations. You are getting them in, so you are doing an whole lot right. Heck man, you might just be on a run of some seriously difficult grade airways also. Getting into the OR for a couple of days would be great. It won't be long, though, and you'll be back to where you were before.

BTW, thanks for your service as an EMS; you all are frontline and incredible at what you do.

AnnieOaklyRN, BSN, RN, EMT-P · Jun 19, 2010

Hey man, I feel for you and understand exactly where you are. I am an RT, and from 2001-2005 I worked two hospitals where we were the primary intubators. They put us through many OR days, and we intubated 98% of the patients that got intubated. After a couple of weeks of difficulty, it got better and better. I became one of the night shift supervisors at the first hospital, and out of my crew, only one other RT had any desire to intubate, but he would always back away and let me do it if he had a choice. In those years, I intubated often, and intubated people on the floor, an obese pt with the bed stuck in trendelenburg, etc., and became very confident.
During my BSN work and my critical care RN work prior to CRNA school, I did not intubate for five years.
When I got into the OR during our first few weeks of clinical, it was as if I'd never held a flipping laryngoscope in my life! I never saw cords on my first four attempts in a very controlled environment, and it was very frustrating. I finally had an easy intubation, and from there out, things have gotten much better. That said, I have continued to experience poorer views at a greater rate than I ever remembered when I was working as an RT. My explanation for this is that I plain didn't remember just how difficult DL and intubation can be. Also, after all the knowledge about the airway and techniques is in your head, it is a SKILL. Any skill becomes better and thus more successful with repetition and experience and diminishes without it. Add to that the conditions you are operating in, and you truly have a situation that will lend to trying intubations. You are getting them in, so you are doing an whole lot right. Heck man, you might just be on a run of some seriously difficult grade airways also. Getting into the OR for a couple of days would be great. It won't be long, though, and you'll be back to where you were before.
BTW, thanks for your service as an EMS; you all are frontline and incredible at what you do.

Thanks for your reply... I am a she though :)