Which laryngoscope blade is your favorite?
Does length matter?
Does strength matter?[1]
Dr. Minh LeCong asks this at his blog PHARM – PreHospital And Retrieval Medicine.
There is also a video that provides some information on blade size.
One of the problems with the video is the hand position. The laryngoscope should be held so that the hand is touching the blade. I prefer to have my ring finger touching the blade.
The higher the hand is on the handle, the more likely that the handle is used like a slot machine handle, as I demonstrate below.
The way to intubate is to position the patient before even picking up the laryngoscope (and premedicating with oxygen and whatever else is appropriate), then only advance the blade as far as necessary for each step of laryngoscopy.
1. Find the tongue.
Yay! That was easy.
2. Advance the laryngoscope and find the epiglottis.
Not as easy, but just more important.
3. Lift up (either in the valecula or under the epiglottis – it does not matter) and find the arytenoid structures. The vocal cords are above the arytenoid structures, so there is no need to lift up any farther.
4. Advance the bougie/tube over the arytenoid structures without touching anything else. It isn’t about cleanliness. The biggest problem I see people have when trying to intubate is that they do not avoid everything else in the mouth and end up trying to force the tube.
Force should never be used in the airway.
We should not arm wrestle with the airway. We will lose.
Go ahead and try to force this airway. I double dog dare you.
Image credit. It is all in the positioning.
The goal of airway management is to out-think the airway, not to out-muscle the airway.
As with martial arts, strength improves with repetition due to the development of muscle memory, even if there is no increase in strength. Technique requires a lot of repetition.
If you have not intubated a mannequin over a thousand times, you are still learning technique. We can always learn more.
We tend to be satisfied with very little practice, as if the patient owes it to us to inhale the tube.
This is ridiculous, but I find that for almost every class I have taught, I intubated the mannequin more times than everyone else in the class combined. I offer to let students practice as much as they want. I offer to help or to leave them alone.
Why is intubation of the airway of another human being so unimportant to so many of us?
Why do so many of us pretend that we are good at intubation?
Intubation shouldn’t be that hard, but research repeatedly shows us that we become airway stupid when things do not go as planned – and we are often the cause of the problems with our plan. Even if our plan is not just having the patient inhale the tube.
Most adults can be intubated with a #2 Mac or a #2 Miller. A longer blade is only necessary for a patient with an unusually long mandible.
Understanding of the airway is more important than blade size. Any spatula will do.
A blade should be relatively wide and flat. A tongue depressor would work well, but this would require some practice to manipulate the tongue with a tongue depressor. A tongue depressor is wider and flatter than a Miller, so a tongue depressor is better designed than a Miller to lift the tongue out of the way.
Why isn’t the Miller blade designed to lift the tongue out of the way? Was Miller in cahoots with the trial lawyers?
I prefer a Grandview, but a lower profile Grandview would be nice.
This is from Dr. Richard Levitan’s Airway Cam series.
Dr. Levitan is one of the top airway doctors in emergency medicine. Notice how low his hand is on the blade. It may be someone else manipulating the laryngoscope, but probably someone who has received input from Dr. Levitan on intubation technique.
The wrist is lower than the blade. This makes it more difficult to pull back on the blade and easier to lift up with the blade.
Intubation is not about a long blade, or a strong arm, or pulling back, but many people attempt to intubate using all three of these mistakes.
Intubation is about thinking, preparation, positioning, technique, and lifting the tongue up.
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Footnotes:
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[1] PHARM Poll : Blade choice in direct laryngoscopy – does length or strength matter?
by rfdsdoc
on May 2, 2013
PHARM – PreHospital And Retrieval Medicine
Article
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One interesting fact, the single most popular size blade in hospitals is #3, in EMS it is #4. We use blades that are often too big. I met one leading anesthesiologist who rarely uses anything bigger than #2.
Dan,
This is true. We appear to be so afraid of not having enough, that we do not think about how too long a blade interferes with our ability to intubate.
As the first video shows, the longer the blade, the more force we need to hold the blade steady.
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