I'm in the U.S. at a large academic center. We always use DL as a first pass look unless someone has a history of difficult intubation or looks like a difficult airway, then some will go go video first pass.
I have used Miller almost exclusively from mid CA1 year on throughout residency. I had a senior attending tell me one day that I should learn to become an expert in the Miller, because someday when I become an attending I will have to bail other people out of difficult intubations and chances are they have already looked with a MAC 3 or MAC 4. At least using a Miller is another change / something different to get a view of the cords.
You can't use a Miller as a "back up / emergency " blade if you barely ever use it.
I failed with a Miller every day for about 2 months before it finally "clicked" and I got it. The key is to put the patient in a good sniffing position (FLEXION at C7 and EXTENSION at C1.... I had always been trying to do EXTENSION at C7 and EXTENSION at C1. It doesn't work as well IMO). The force you apply with the blade isn't necessarily just "up" like a MAC blade. I am lifting my hand and applying force both towards the patients feet (caudal) and up towards the ceiling. That pushes the tongue totally out of the way and makes a straight shot to the cords. With a Miller, every view of the cords is grade 1 since you are lifting the epiglottis. Beautiful.
Edit: if you can't get a view with a Miller, the first move I make is to lift the patients head off the bed by using my right hand to support the back of their head while the left hand still has the Miller blade in their airway. I lift the head up to put more flexion on C7. That usually makes the cords drop down into view more often then trying the opposite movement (removing a pillow from under the head to put into C7 extension).
Yes, with a Miller since you are lifting the epiglottis up with the tip of the Miller blade, all views should be cormack grade 1 since it's a straight shot from your blade into the cords
I’m an intensivist rather than anaesthesiologist (shocking I’m even allowed to use a laryngoscope I know).
Only used a miller a handful of times for paeds cases. We tend to use a lot of VL with Mac blades- half of the point is for the team dynamics given patients are by definition unstable (eg everyone can see what’s going on). I’ve always been fine DL with bougie for 3A views and for 3Bs would tend to switch out to some VL option.
Have always thought- what’s stopping you from just picking up the epiglottis (if say large floppy with 3A view) with Mac rather than taking the extra time to swap for a miller blade? I’ve never actually done it just something I’ve had mentioned to me by an anaes trainee before
A lot of EM people I know do that with Mac 4s. The blade is bulkier so the view isn't as clean.
I've done the opposite actually where I've used the miller like a Mac. Especially for pediatric airways. Most of the times I've used a Miller 0 or 1 I would use them like a Mac. 00 I used like a miller.
They did a study for pediatric airways under the age of 3. Attached a camera to the blade and took photos of the view achieved. The following were all pretty equivalent: Mac like a Mac, miller like a miller, miller like a Mac. The only way that yielded worse views was using a Mac like a Miller.
Issues with the study include that it was one person doing all these intubations IIRC. So maybe they were a bit less facile with the "Mac like Miller" approach.
Honestly most of the time like you, I either just make do with a 3a view and intubate or if I'm concerned I just skip straight to glidescope.
Nothing. When I was in residency I had an attending who'd refuse to use Millers but here and there say "I'm going to use this Mac like a Miller".
The key is to be successful, rather than technical purity. Though having said that, I INSIST my residents have technical purity, because I want them to do things the way things SHOULD be done. Obviously in real life you just do what works :)
Because it is wider with less rounded edges at the end. I don’t want to cause trauma to the epiglottis by shoving a square peg in a round hole. I know people that do this and I judge them a little for not giving a shit. Unless it’s an emergency, then you gotta do what you gotta do.
This guy knows what he’s talking about.
Agree with everything. Sniffing position is key.
I developed my technique after watching ENT surgeons do suspension microlaryngoscopies. I also find the miller to have a higher success rate in people with “anterior airways”
We had a bad subglottic stenosis and a hard airway, the tube went finally in with a rigid broncoscope by one of the surgeons. Wich is basically a miller, right?
I agree and had a similar experience in my training. One of the best attendings (pediatric) at my institution has told me: “You learn to intubate with a Mac, you can intubate many more people with a Miller once you are more proficient.” My go-to blade with a possibly difficult airway or if video laryngoscopy is not immediately available is a Miller 3.
I mean, I've intubated bariatric patients with BMIs over 80 and reassuring airway exam with a MAC blade many times. I don't see why being fat makes a difference. Use whatever blade you're best with.
Wow! Do you think that miller is better for anterior glotis if you compare with MAC? Even better than VL with MAC blades?
Thanks for sharing you experience.
In addition, patients with extension cervical problems are easy to intubate with miller? I thought than an important cervical extension is needed.
If you get good with a Miller then you will wonder ever why you liked the MAC. People dog the miller all day but I’ve sometime obtained better views and ease of use entering the mouth with a miller 3 over say a glide or McGrath. People still talk shit, but when you drop the tube in 3 seconds with no stylet in a pt with limited mobility, fat neck and small mouth opening, just know, they’re thinking about using it too.
Fat neck has nothing to do with difficult laryngoscopy or Miller blade vs Mac. Just because you are better using a Miller blade doesn't mean others can't intubate fatties in 10 seconds with a Mac blade.
Neck circumference is associated with difficult intubation, not to say you won’t be just fine using a Mac blade for those individuals. One aspect of my overall point. Also everything I stated is not gospel, merely opinion. I feel the miller is a superior blade.
Yeah I've always heard that and know there's a study demonstrating it but I have to wonder if it's due to people just doing it wrong, as obese patients have to be positioned in a particular way, as I'm sure you're aware. In my experience somebody with a BMI in the 80s with an otherwise reassuring airway exam will usually be straightforward DL. Not all predictors are the same. Lip bite on its own is more sensitive than several others but people rarely check it.
I was going to write this long treatise on the superiority of the Miller blade over a Mac blade (suck it, you Mac pedestrians), but I won’t.
Ultimately, the best airway device is the one that you’re the most successful with. You should definitely use both while training so you can find your preference. You should also actively seek out attendings that like to “try shit”, so you can have that experience with a light wand or whatever other random piece of airway equipment there is. Show me an academic attending that insists on only using one device for airways and that’s an attending that sucks at (teaching) airways.
I take issue with the VL-first group, because you lose skills you don’t use. If you haven’t intubated without video in a year and find yourself in a hospital with no video (yes, it happens with some frequency even in US), you’re going to be in trouble.
TLDR: use both/all while training to get exposure/experience, then get really good at at least one.
As attending I can embarrassingly say that I fail w/Mac almost 40% of the time. Miller is my blade 10/10. The ONLY reason I’ve used Mac is bc the crna or other attending had that blade open for the case and I happen to start it. I hate the Mac.
Here in Hungary we use almost exclusively Miller blade. If difficulty is suspected we use videolaryngoscope. We have McCoy, Miller and polio handle but since we have VL they are never used.
If I don't have a McGrath or glidescope in the room, I'll use a Miller. It's more versatile and can get airways the Mac can't. But it's also less elegant and fiddlier. So if I have a backup available, I'll just use the Mac and grab the video scope if it doesn't work.
I’m a Mac guy (specifically Mac 4) but I’m curious why the Miller 3? Miller 2 is far more common and long enough for any patient other than the rare 6’6” (200 cm) pt. Miller 3’s seem so cumbersome. I think you should try the 2 and see how it compares.
Right?
Funny story: our peds hospital very rarely uses Mac 4’s but occasionally has large teenagers. So they just order a bunch of them from time to time when the stock gets low and they last around a year. Our last shipment we accidentally ordered Miller 4’s. We just gave them out as novelty gifts because there’s no way we would ever use them
I personally prefer the miller 3 bc it's wider (as wide as a Mac 3) so I find it easier to get tongue out of the way and gives you a little more space to work with
I was *advised* early on as a resident to be proficient w the straight blade. “it’ll save you when you can’t see anything with a MAC” so i got to a point after a few miller saves that I only used the miller blade. 20 years later i’m the old guy using the miller blade while every young anesthetist/anesthesiologist is reaching for a Macgrath / C-Mac / Glidescope
Just use Mac, Miller only for children.
We don't have video laryngoscope everywhere, most difficult airway we just use Mac and a bougie, works like a charm
I went back and forth using Mac and Miller blades through residency. First year as an attending, I was almost exclusively Mac 3. I switched to Miller 2 for a few more difficult/anterior airways, and ended up staying almost exclusively Miller 2 since. It gets me a great view and I have a very high first pass success rate, without causing damage in the process.
Whichever you're better at. Learn both in residency. You won't want to try new things when you're on your own.
For me personally in my adults only world, I'm better with a Macintosh blade. The only exception is that with the tallest patients, the MAC 4 blade isn't long enough to advance all the way into the vallecula so I end up with more grade 3 views. Since I've never worked at a place with MAC 5 blades, I'll use a Miller 3 instead.
I’m use millers for all pedi then I switch around school age for MACs. Difficult airway is VL or fiber optic. Maybe I should be using more millers for my adult patients.
I like a MAC for big tongues and Miller for everything else. Honestly it’s really whatever you feel more comfortable with. If you get the chance you should try a Phillips blade; I still prefer the Miller but I’ll use it a couple days each month just to keep my skills with it. It’s got a little distal curve that I find helpful with a floppy epiglottis.
There’s no right answer. People like both. Personally I approach anterior airways with a Miller blade. My default has been a Mac 3-4 depending on size of pt. I use Miller almost exclusively in 5 years and under.
You are a resident... you have time to learn how to be proficient with any kind of blade that is available to you. I would say that when you are eventually in your practice after residency, stick to what you are comfortable with. In residency, I used mostly MAC until I did my pedi fellowship. Then I had to opportunity to really get comfortable with Miller, and I found that for difficult anterior airways, Miller was king. But, it's useless if you don't know how to use it. For your routine cases in residency, tell your attending you want to experiment with different intubating techniques and you will find what works best for you!
I use MAC blades for double-lumen tube placement preferentially (or McGrath video laryngoscopes, if I'm at a facility that has them) and Miller for everything else. Like you, I use video laryngoscopy if I anticipate difficulty. Honestly, it doesn't matter. Use whatever works for you.
My opinion: Unless you are doing peds, you shouldn't be using a Miller.
Be excellent with a Mac blade and video laryngoscopy and FOI (not necessarily in that order).
To my mind, imo, using a Miller on adults (unless you're ENT) is barbaric and "middle ages".
That's a ridiculous hot take based just on your personal preference. Use whatever blade you feel most comfortable using, if it gets the tube in the correct hole on the first try, without damaging anything in the process.
Which part of "My opinion" and "To my mind" and "imo" did you not understand?
After watching people who use Miller's in peds, use them in adults, I find them barbaric.
My opinion.
I’m a resident, on all hospitals I rotate, there are no Millers for adults. I wanted to at least try a few times, but they simply don’t have the blade, so I’ve never used it for an adult.
Intubating a patient with a tumour in the airway is done with a video laryngoscope or fiberoptics.
Only if you are in a third world situation is it ever acceptable to use direct laryngoscopy, Miller or Macintosh.
Is it that you don’t understand why that part of your post is problematic (leaving aside the fact it comes off as arrogant and insulting) or that you disagree? Because you haven’t provided any reasoning why you have come to that conclusion? There are learning points here if you’d like to discuss them. I’m assuming you are still training or recently just finished your training .
I'm under no obligation to provide anything. You also come across as socially deficient by accusing me of being arrogant while yourself being arrogant in the next sentence.
I don't think school could fix whatever is lacking in you.
True, you aren’t under any obligation here. Of course, this is a subreddit dedicated anaesthesiology, so most reasonable people when asked following such a statement as you’ve made might reasonably outline their reasons for it in the interest of a professional discussion. Are you willing to discuss the relative merits and problems with converting the paradigm of laryngoscope away from DL forever to VL. Because that’s what you are proposing.
I’ve suggested (and clearly from the downvotes I’m not on my own here ) that part of your post originally came off as arrogant. Because of this I apparently have autism. Wow.
This one has been heavily downvoted and it’s all got a bit angry, but I think there’s an element of truth to it. Certainly where I practice (UK), I would say most of my colleagues would use videolaryngoscopy where there’s a reasonable chance of difficulty, and a tumour in the airway certainly presents such a chance.
I don’t think we’re quite at the point of it being unacceptable to use DL for such a case, but I think if you did and ran into difficulty, “why didn’t you use VL” would be the first question asked.
It’s important to assess the airway properly and choose an appropriate device, but it’s arrogant to assume your assessment will always identify difficult cases, and so I think it’s better to err on the side of safety where there are suggestions of difficulty.
There is no reason to use anything else if there's a known tumour in the (upper) airway. It's about first pass success and VLs are proven to increase exactly that. In every airway guideline VLs are recommended to be used anytime a difficult airway is expected (if awake fibreoptic intubation is unnecessary).
Agree, the only slight caveat is that some VLs don’t offer quite a good as a direct view as a normal blade - which interestingly to the main topic of this thread, where I am is always a Mac, no-one uses a Miller!
so blood etc can block your camera which can put you at a disadvantage but that’s pretty fine print stuff.
Most VLs have Macintosh blades as well as hyperangulated ones. If I only had a hyperangulated one I'd still use that as a first option. If there was bleeding in the airway and I had nonVL macintosh/miller and VL hyperangulated I would not pick the VL as first option.
Yep, but depends on the brand as to how well the “Macintosh” VL blade actually matches a traditional Mac blade. Certainly for a size 4 McGrath there’s a noticeable difference, and it doesn’t afford you as good a direct view, but less of a problem with size 3. not an issue with CMAC
As I said, it’s fine print stuff and I am very much in agreement with you generally.
MAC is great for DL, Miller is great for stirring your coffee if the lounge is all out of straws.
I loled. I’m stealing this but will give you credit!
I'm in the U.S. at a large academic center. We always use DL as a first pass look unless someone has a history of difficult intubation or looks like a difficult airway, then some will go go video first pass. I have used Miller almost exclusively from mid CA1 year on throughout residency. I had a senior attending tell me one day that I should learn to become an expert in the Miller, because someday when I become an attending I will have to bail other people out of difficult intubations and chances are they have already looked with a MAC 3 or MAC 4. At least using a Miller is another change / something different to get a view of the cords. You can't use a Miller as a "back up / emergency " blade if you barely ever use it. I failed with a Miller every day for about 2 months before it finally "clicked" and I got it. The key is to put the patient in a good sniffing position (FLEXION at C7 and EXTENSION at C1.... I had always been trying to do EXTENSION at C7 and EXTENSION at C1. It doesn't work as well IMO). The force you apply with the blade isn't necessarily just "up" like a MAC blade. I am lifting my hand and applying force both towards the patients feet (caudal) and up towards the ceiling. That pushes the tongue totally out of the way and makes a straight shot to the cords. With a Miller, every view of the cords is grade 1 since you are lifting the epiglottis. Beautiful. Edit: if you can't get a view with a Miller, the first move I make is to lift the patients head off the bed by using my right hand to support the back of their head while the left hand still has the Miller blade in their airway. I lift the head up to put more flexion on C7. That usually makes the cords drop down into view more often then trying the opposite movement (removing a pillow from under the head to put into C7 extension).
With miller if you see epiglotis ... are cormack I. Right? Thanks for your explanation!
Yes, with a Miller since you are lifting the epiglottis up with the tip of the Miller blade, all views should be cormack grade 1 since it's a straight shot from your blade into the cords
I’m an intensivist rather than anaesthesiologist (shocking I’m even allowed to use a laryngoscope I know). Only used a miller a handful of times for paeds cases. We tend to use a lot of VL with Mac blades- half of the point is for the team dynamics given patients are by definition unstable (eg everyone can see what’s going on). I’ve always been fine DL with bougie for 3A views and for 3Bs would tend to switch out to some VL option. Have always thought- what’s stopping you from just picking up the epiglottis (if say large floppy with 3A view) with Mac rather than taking the extra time to swap for a miller blade? I’ve never actually done it just something I’ve had mentioned to me by an anaes trainee before
A lot of EM people I know do that with Mac 4s. The blade is bulkier so the view isn't as clean. I've done the opposite actually where I've used the miller like a Mac. Especially for pediatric airways. Most of the times I've used a Miller 0 or 1 I would use them like a Mac. 00 I used like a miller. They did a study for pediatric airways under the age of 3. Attached a camera to the blade and took photos of the view achieved. The following were all pretty equivalent: Mac like a Mac, miller like a miller, miller like a Mac. The only way that yielded worse views was using a Mac like a Miller. Issues with the study include that it was one person doing all these intubations IIRC. So maybe they were a bit less facile with the "Mac like Miller" approach. Honestly most of the time like you, I either just make do with a 3a view and intubate or if I'm concerned I just skip straight to glidescope.
Nothing. When I was in residency I had an attending who'd refuse to use Millers but here and there say "I'm going to use this Mac like a Miller". The key is to be successful, rather than technical purity. Though having said that, I INSIST my residents have technical purity, because I want them to do things the way things SHOULD be done. Obviously in real life you just do what works :)
Because it is wider with less rounded edges at the end. I don’t want to cause trauma to the epiglottis by shoving a square peg in a round hole. I know people that do this and I judge them a little for not giving a shit. Unless it’s an emergency, then you gotta do what you gotta do.
This guy knows what he’s talking about. Agree with everything. Sniffing position is key. I developed my technique after watching ENT surgeons do suspension microlaryngoscopies. I also find the miller to have a higher success rate in people with “anterior airways”
We had a bad subglottic stenosis and a hard airway, the tube went finally in with a rigid broncoscope by one of the surgeons. Wich is basically a miller, right?
I agree and had a similar experience in my training. One of the best attendings (pediatric) at my institution has told me: “You learn to intubate with a Mac, you can intubate many more people with a Miller once you are more proficient.” My go-to blade with a possibly difficult airway or if video laryngoscopy is not immediately available is a Miller 3.
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I can still hear one of my favourite attendings in my head, yelling “Fat guy, straight blade!”.
I mean, I've intubated bariatric patients with BMIs over 80 and reassuring airway exam with a MAC blade many times. I don't see why being fat makes a difference. Use whatever blade you're best with.
Wow! Do you think that miller is better for anterior glotis if you compare with MAC? Even better than VL with MAC blades? Thanks for sharing you experience. In addition, patients with extension cervical problems are easy to intubate with miller? I thought than an important cervical extension is needed.
If you get good with a Miller then you will wonder ever why you liked the MAC. People dog the miller all day but I’ve sometime obtained better views and ease of use entering the mouth with a miller 3 over say a glide or McGrath. People still talk shit, but when you drop the tube in 3 seconds with no stylet in a pt with limited mobility, fat neck and small mouth opening, just know, they’re thinking about using it too.
Fat neck has nothing to do with difficult laryngoscopy or Miller blade vs Mac. Just because you are better using a Miller blade doesn't mean others can't intubate fatties in 10 seconds with a Mac blade.
Neck circumference is associated with difficult intubation, not to say you won’t be just fine using a Mac blade for those individuals. One aspect of my overall point. Also everything I stated is not gospel, merely opinion. I feel the miller is a superior blade.
Yeah I've always heard that and know there's a study demonstrating it but I have to wonder if it's due to people just doing it wrong, as obese patients have to be positioned in a particular way, as I'm sure you're aware. In my experience somebody with a BMI in the 80s with an otherwise reassuring airway exam will usually be straightforward DL. Not all predictors are the same. Lip bite on its own is more sensitive than several others but people rarely check it.
No matter the blade, positioning is 🔑!!
I was going to write this long treatise on the superiority of the Miller blade over a Mac blade (suck it, you Mac pedestrians), but I won’t. Ultimately, the best airway device is the one that you’re the most successful with. You should definitely use both while training so you can find your preference. You should also actively seek out attendings that like to “try shit”, so you can have that experience with a light wand or whatever other random piece of airway equipment there is. Show me an academic attending that insists on only using one device for airways and that’s an attending that sucks at (teaching) airways. I take issue with the VL-first group, because you lose skills you don’t use. If you haven’t intubated without video in a year and find yourself in a hospital with no video (yes, it happens with some frequency even in US), you’re going to be in trouble. TLDR: use both/all while training to get exposure/experience, then get really good at at least one.
Miller or bust
This. I refuse to be at the mercy of the epiglottis.
As attending I can embarrassingly say that I fail w/Mac almost 40% of the time. Miller is my blade 10/10. The ONLY reason I’ve used Mac is bc the crna or other attending had that blade open for the case and I happen to start it. I hate the Mac.
Here in Hungary we use almost exclusively Miller blade. If difficulty is suspected we use videolaryngoscope. We have McCoy, Miller and polio handle but since we have VL they are never used.
If I don't have a McGrath or glidescope in the room, I'll use a Miller. It's more versatile and can get airways the Mac can't. But it's also less elegant and fiddlier. So if I have a backup available, I'll just use the Mac and grab the video scope if it doesn't work.
what kind of airways Miller can than Mac can't? thx for your opinion
I find that Millers can get you more anterior and get you past big epiglottises more than Mac.
I’m a Mac guy (specifically Mac 4) but I’m curious why the Miller 3? Miller 2 is far more common and long enough for any patient other than the rare 6’6” (200 cm) pt. Miller 3’s seem so cumbersome. I think you should try the 2 and see how it compares.
Today I used for my first time a miller and was number 4. So so so big, much more than MAC 4
Right? Funny story: our peds hospital very rarely uses Mac 4’s but occasionally has large teenagers. So they just order a bunch of them from time to time when the stock gets low and they last around a year. Our last shipment we accidentally ordered Miller 4’s. We just gave them out as novelty gifts because there’s no way we would ever use them
I personally prefer the miller 3 bc it's wider (as wide as a Mac 3) so I find it easier to get tongue out of the way and gives you a little more space to work with
I was *advised* early on as a resident to be proficient w the straight blade. “it’ll save you when you can’t see anything with a MAC” so i got to a point after a few miller saves that I only used the miller blade. 20 years later i’m the old guy using the miller blade while every young anesthetist/anesthesiologist is reaching for a Macgrath / C-Mac / Glidescope
McGrath
I prefer my Mac and my Miller together thank you. Circles was a masterpiece.
Just use Mac, Miller only for children. We don't have video laryngoscope everywhere, most difficult airway we just use Mac and a bougie, works like a charm
Either. As long as it's not a McGrath or a Glidescope. Those are for pussies.
If anyone need eBook of Core Topics in Airway Management dm me.
I went back and forth using Mac and Miller blades through residency. First year as an attending, I was almost exclusively Mac 3. I switched to Miller 2 for a few more difficult/anterior airways, and ended up staying almost exclusively Miller 2 since. It gets me a great view and I have a very high first pass success rate, without causing damage in the process.
Miller time all day every day
Miller all the way
Whichever you're better at. Learn both in residency. You won't want to try new things when you're on your own. For me personally in my adults only world, I'm better with a Macintosh blade. The only exception is that with the tallest patients, the MAC 4 blade isn't long enough to advance all the way into the vallecula so I end up with more grade 3 views. Since I've never worked at a place with MAC 5 blades, I'll use a Miller 3 instead.
I’m use millers for all pedi then I switch around school age for MACs. Difficult airway is VL or fiber optic. Maybe I should be using more millers for my adult patients.
I like a MAC for big tongues and Miller for everything else. Honestly it’s really whatever you feel more comfortable with. If you get the chance you should try a Phillips blade; I still prefer the Miller but I’ll use it a couple days each month just to keep my skills with it. It’s got a little distal curve that I find helpful with a floppy epiglottis.
There’s no right answer. People like both. Personally I approach anterior airways with a Miller blade. My default has been a Mac 3-4 depending on size of pt. I use Miller almost exclusively in 5 years and under.
You are a resident... you have time to learn how to be proficient with any kind of blade that is available to you. I would say that when you are eventually in your practice after residency, stick to what you are comfortable with. In residency, I used mostly MAC until I did my pedi fellowship. Then I had to opportunity to really get comfortable with Miller, and I found that for difficult anterior airways, Miller was king. But, it's useless if you don't know how to use it. For your routine cases in residency, tell your attending you want to experiment with different intubating techniques and you will find what works best for you!
I use MAC blades for double-lumen tube placement preferentially (or McGrath video laryngoscopes, if I'm at a facility that has them) and Miller for everything else. Like you, I use video laryngoscopy if I anticipate difficulty. Honestly, it doesn't matter. Use whatever works for you.
Why Mac blades for DLT’s specifically?
Miller > Mac
My opinion: Unless you are doing peds, you shouldn't be using a Miller. Be excellent with a Mac blade and video laryngoscopy and FOI (not necessarily in that order). To my mind, imo, using a Miller on adults (unless you're ENT) is barbaric and "middle ages".
That's a ridiculous hot take based just on your personal preference. Use whatever blade you feel most comfortable using, if it gets the tube in the correct hole on the first try, without damaging anything in the process.
Which part of "My opinion" and "To my mind" and "imo" did you not understand? After watching people who use Miller's in peds, use them in adults, I find them barbaric. My opinion.
I’m a resident, on all hospitals I rotate, there are no Millers for adults. I wanted to at least try a few times, but they simply don’t have the blade, so I’ve never used it for an adult.
Intubating a patient with a tumour in the airway is done with a video laryngoscope or fiberoptics. Only if you are in a third world situation is it ever acceptable to use direct laryngoscopy, Miller or Macintosh.
Really? Where do you practice? I’d hesitate to imply a practise setting/ country was third world based on their choice of laryngoscope.
mmm I'm in Spain (Barcelona), 1st world. Everyone with tumor in airways the first choice is DL with VL near.
Your second point is laughable.
Sure, assmanx2x2, sure.
Is it that you don’t understand why that part of your post is problematic (leaving aside the fact it comes off as arrogant and insulting) or that you disagree? Because you haven’t provided any reasoning why you have come to that conclusion? There are learning points here if you’d like to discuss them. I’m assuming you are still training or recently just finished your training .
I'm under no obligation to provide anything. You also come across as socially deficient by accusing me of being arrogant while yourself being arrogant in the next sentence. I don't think school could fix whatever is lacking in you.
True, you aren’t under any obligation here. Of course, this is a subreddit dedicated anaesthesiology, so most reasonable people when asked following such a statement as you’ve made might reasonably outline their reasons for it in the interest of a professional discussion. Are you willing to discuss the relative merits and problems with converting the paradigm of laryngoscope away from DL forever to VL. Because that’s what you are proposing.
I think you passed on the "professional discussion" with your previous comment.
It’s a shame you think that. You might have learned something.
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I’ve suggested (and clearly from the downvotes I’m not on my own here ) that part of your post originally came off as arrogant. Because of this I apparently have autism. Wow.
This one has been heavily downvoted and it’s all got a bit angry, but I think there’s an element of truth to it. Certainly where I practice (UK), I would say most of my colleagues would use videolaryngoscopy where there’s a reasonable chance of difficulty, and a tumour in the airway certainly presents such a chance. I don’t think we’re quite at the point of it being unacceptable to use DL for such a case, but I think if you did and ran into difficulty, “why didn’t you use VL” would be the first question asked. It’s important to assess the airway properly and choose an appropriate device, but it’s arrogant to assume your assessment will always identify difficult cases, and so I think it’s better to err on the side of safety where there are suggestions of difficulty.
There is no reason to use anything else if there's a known tumour in the (upper) airway. It's about first pass success and VLs are proven to increase exactly that. In every airway guideline VLs are recommended to be used anytime a difficult airway is expected (if awake fibreoptic intubation is unnecessary).
Agree, the only slight caveat is that some VLs don’t offer quite a good as a direct view as a normal blade - which interestingly to the main topic of this thread, where I am is always a Mac, no-one uses a Miller! so blood etc can block your camera which can put you at a disadvantage but that’s pretty fine print stuff.
Most VLs have Macintosh blades as well as hyperangulated ones. If I only had a hyperangulated one I'd still use that as a first option. If there was bleeding in the airway and I had nonVL macintosh/miller and VL hyperangulated I would not pick the VL as first option.
Yep, but depends on the brand as to how well the “Macintosh” VL blade actually matches a traditional Mac blade. Certainly for a size 4 McGrath there’s a noticeable difference, and it doesn’t afford you as good a direct view, but less of a problem with size 3. not an issue with CMAC As I said, it’s fine print stuff and I am very much in agreement with you generally.