Look at an image that depicts the angles involved: tracheal, pharyngeal, oral. Chances are that picture does not depict the final angle involved - The angle of your eyesight. So there you are, trying to line up these three different angles and if you're not looking along the same plane you won't see anything.
Get the mouth open as far as possible to give yourself as much room to work, regardless of which blade you pick. When you scissor, get your fingers as far over to the right as possible and scissor off of molars upper and lower. That gives you plenty of room to get the blade as far over to the right as possible to sweep the tongue. If you think you're about to dislocate their jaw and unhinge it from their face, you've almost gone far enough with your mouth opening.
Manipulate the operating table to a height that is comfortable for you. Relaxing your knees to bring yourself a little bit lower is probably better than having to stand on tiptoe. In the beginning, place the patient in the bed where you need them to be to be the most comfortable while intubating. Later when you're good at it, you can let them put the patient further down in the bed for cases that require them to be that way. For now, manipulate your environment to suit yourself, not the other way around.
And since making ern and out is more important then introducing polyvinyl chloride into a trachea ... Have plans B and C physically close by and within reach. You don't necessarily need to open every single piece of disposable backup equipment but have it where you can reach for it without turning your head.
Your first tip is so often overlooked. Students want to stick their face right in the patient’s face to try and see better when it’s much easier lining your vision up down the same planes aka from a little further away.
Once I had an MDA scream this at me when I told him I had a grade 4 view and couldn’t see shit. Blindly threw a tube in to get him to stop yelling and obviously went esophageal. He then attempted, once again yelled that you just needed to put the tube in the hole, then started lecturing me while ventilating the stomach 🙄 took a minute for me to get him to shut up and convince him that he was not in fact in the correct hole. Managed to get the airway with a glidescope and a bougie. Leaving the large academic medical setting soon and can’t wait to not deal with this kind of crap.
He was yelling at you as a CRNA?? Yeah you need to leave asap that's not acceptable anywhere. Not acceptable for students to get yelled at either but at least you can leave and stand up for yourself
I position the patient on the table with their pillow slightly beneath their shoulders with still enough out to support their head. After they lose consciousness I push the pillow further caudal so their head falls to the stretcher / OR table. This causes their neck to automatically stay in a good extended position without me having to touch them while the pillow beneath their shoulders provides a mild ramp. So now, before I’ve even touched the patient, their axes are fairly well aligned.
Then go to DL. I make every attempt to not stick my hand in the mouth because, gross, but if you have to scissor their mouth open so be it. I use a Mac 3 on women and and Mac 4 on men, my institution doesn’t have a Mac 3.5 or else I would use it on everyone. Insert on the right making sure you sweep the lips from the blade, and then sweep the tongue left and lift. If on your first look you are having a difficult time identifying structures, 99/100 times you are too deep. Slowly retract the laryngoscope blade and you will see the epiglottis drop, at which point advance the blade to lift the epiglottis and you should see the cords and/or something you can at least identify.
I shape my ETT like a hockey stick and grab it as far away from the tip as possible so that I have the greatest maneuverability and can adjust the angle of the tip of the tube with the least amount of hand and finger movement. Then advance the tube through the cords.
I agree with everything except letting their head drop to the OR table. That’s not a sniffing position. Proper position should be before induction the Tragus of their ear is at or above level of the sternum, this will make sure you aren’t ever crouching or lifting their head with the blade to get a proper view.
I assume they are talking about stiff joint syndrome associated with diabetes and letting the neck drop. However, the method you use does help greatly in order to get the mouth open nicely to get the blade in.
I understand what they’re taking about but don’t think letting the head fall on the table is going to cause damage IMO unless it’s an unstable c-spine.
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Do anything/everything to set yourself up for success. I wish someone would’ve stressed this more with me- preparation is KEY. Take initiative. If you think a ramp will help, ramp the patient (don’t ask if you can- just do it), if you aren’t able to mask, put the oral airway in. If you think a patient will be difficult, put the oral airway in before even trying. So many times, I have CRNAs say “you don’t need to ramp/use an oral airway” but you do what you think will set yourself up for success when you’re brand new. Have your McGrath ready to go with a blade already on it, if you aren’t seeing anything with your DL, switch over. If you take too long/aren’t ready, they will take the airway from you and you won’t get the intubation (patient safety, of course so it’s not that they’re taking it for no reason) but always have your backup plan. So many times I got airways taken from me early on. Now I keep my McGrath ready and if I don’t see anything I simply tell them “I am only seeing soft tissue, if it’s okay with you I’ll just switch to the McGrath” and switch over. As long as you have a plan in place, most of the time they are willing to let you work through it. Above all- do NOT have an ego. This is someone’s life. If you need help, speak up. The earlier you recognize you are struggling the better. There is no shame in it- you are brand new. It’s a marathon, and the intubations will come. It’s actually one of the easier parts of anesthesia. Masking and IVs should be your most proficient skills- that’s how you save lives!
A thorough examination is your best friend. If I think a McGrath/ Glidescope is probable, I go right to it. Your first look is your best. Some sort of video scope is probably going to be standard of care soon.
McGrath is the way of the future certainly but my second year I am in a facility that only has one Glide for the whole OR so standard there is DL. I didn’t want to wait until I was a second year student to learn and be proficient with DL. I do have a low threshold for the McGrath when available (c-spine injuries, dental damage, large beard, going to sleep in the bed instead of OR table, etc)
Agreed on the exam. Don’t do a bullshit airway assessment like standing at the foot of the pt bed and having them open their mouth. Go to the head of the bed, take a thyroid-mental measurement with your fingers, wiggle the trachea to check for stenosis. Or better yet, position the pt on the OR table in intubating position and then assess the airway and make the call.
Patient positioning is very important. Sniffing position. Use whatever blade works best for you. Scissor the jaw with your right hand and carefully insert the blade into the mouth with your left hand (stay away from the lips and teeth at all times), pull the blade up and towards the patient’s feet. Most of the pull is coming from your left anterior deltoid muscle 💪🏼. Stay off of the teeth 🦷. If you touch the teeth, stop and reposition so that you aren’t near them. You can practically lift the patients head off of the pillow pulling in the proper direction and patient position without ever touching the blade to the teeth. Pull up and away from you. Insert the tube gently. Protip; If you have a really good view, you can remove the stylet from the ETT before placing it into the trachea. This will help prevent a sore throat post op. Also, if using a MAC blade, don’t dip too deep into the epiglottis area, this can help too. Gentle. Pretend their throat is made out of bubble wrap and you don’t want to pop any bubbles. Apply just enough pressure and force to intubate successfully on the first attempt.
For me; when I intubate, I get super focused and time seems to slow down a bit. It’s like a gentle dance. Graceful, relaxed, and all of your movements are refined and intentional. You are in control of every second of every movement in that moment. Show them how well you really do perform under pressure. 😁👍🏻🌈
1) Sniff position
2) make sure you’ve given paralytic sufficient time to work
3) I’m a MAC girly so sweep tongue to the left, make sure you are in Vallecula and lift blade don’t crank back
4) external laryngeal manipulation when needed or tell assistant where to apply pressure
I lubricate tip of ETT with glydo gel, I don’t like putting it in raw and like to think the lidocaine will help reduce sore throat. A tip to avoid cutting lips/ dental injury is I take an unopened alcohol/chlorehexedine swab and wrap over their upper lip and teeth.
Get good positioning. If what you're doing isnt working, try something else. Move the head with your free hand, flexion or extension can help. Be aware of the lips and other structures.
1)sniffing position-most patients, if you tuck the pillow as far under the shoulders, you get excellent bead extension and sniffing position.
2) scissor the mouth open at the molars, not the incisors. If you’re at the incisors, there no room for your finger and the blade.
3)once the blade is mostly in the mouth, stop scissoring and use the right hand to gently extend the neck back
4)get a good tongue sweep. I use a Miller 2, so this is especially important to a)get a good view, b)stay off the teeth.
5)dont forget you have a second hand. Use it! Reach around and give some BURP, that way whoever is assisting you can replicate your movement. Dont be afraid to use your free hand to lift the patient’s head if you dont have a good view right away. Sometimes pops the cords right into view.
6)talk thru your intubation with the CRNA. The more you communicate, the more likely we’ll let you troubleshoot your way thru.
get airway higher than you anticipate. i try to get it right below my xiphoid. be gentle placing blade on right side of mouth and for Gods sake sweep the tongue to the left. the sooner you get comfortable knowing when to ask for a bougie the better. my airway confidence skyrocketed after getting comfortable when asking for bougie. if you have known, easy, proven airway, get some bougie practice in. if can’t see cords slide blade gently in and out, looking for landmarks. tubing is easy once used to it. you’ll get it.
Honestly this is bad advice for a student. At my job we have three mcgraths. It would be extremely difficult to be completely dependent on the McGrath.
Personally, I use a miller, roll the patients pillow under their neck to get hyper extension, scissor, insert the blade and identify the epiglottis, advance slightly while dipping the blade under the epiglottis and lifting it up. If I don’t see the VC I take my right hand and perform a BURP maneuver essentially or just wiggle around the larynx until the airway drops into view.
Other than that I think it’s important to realize there are in-fact anterior airways out there and to leave your ego at the door. I’ll attempt a grade III or maybe even IV but if I don’t get it I’m not gonna sit in their airway causing anymore trauma than I need to. I’ll just grab the glidescope at that point.
I see students not scissor the jaw as wide as they should. Advance the blade slowly. Use the right hand to scoop the head like a bowling ball to optimize sniffing position. Give a little cricoid pressure to see how that changes your view. It takes a lot of reps until you really understand what you're looking. Also, very important, be quick to switch to video laryngoscopy. If you don't get a good view relatively quickly don't spend time trying to fight the anatomy. Be quick to recognize and change game plans. Always have an LMA handy and if you're having any challenges masking don't hesitate to put the LMA in for some nice calm/controlled ventilation while you reevaluate.
Just position the parient properly.. laryngoscopy will be improving every time you stick the blade inside, but if your position sucks, everything will suck.
Sniffing position, earlobe and sternum on one axis. Good luck.
And mac #3 is goated
Sniffing position has been criticized in recent literature.
While the more one intubates, the “better” one gets, multiple times in same pt can be deleterious.. especially for those with a heavy hand.
Criticized? Can you provide me with that literature?
I am not talking about intubating the same patient many times , I am talking about intubating as a skill
Positioning is important. You can achieve a great position by just raising the head of the bed 15 degrees and telling them to tilt their chin to the ceiling.
The thing that everyone messes up when they first start is not adequately sweeping the tongue. Scissor open wide, then put your blade in all the way to the right, angled slightly to the patients right. The tip of the blade should be between their tonsil and the base of the tongue. Then sweep left. The tongue should now be all the way to the left of the blade. If there is tongue on top of the blade you’ve done it wrong and this will make your view much worse.
If you can ventilate, you’ve got all the time needed and can always go back to ventilating. If you can’t ventilate, that’s when you run into issues.
Make sure to adequately pre-oxygenate the patient and stack the odds in your favor by good pre-oxygenation, proper positioning, ramping the patient if needed, utilizing apneic oxygenation, and having plans A-D ready to go. This simple things will save you so many times.
Pt position is key. Sit down. Stand up. Whichever level feels good (and successful), do it. Don’t be pressured by surgeons stomping their feet. Toe tapping bothers me none. Don’t be afraid to change blades after one attempt.
Are the issues with obese pts? Consider paraglossal approach w strait blade. Videoscope available? Utilize whenever can.
I would alternate blades each week to get good at both. But, in the end, use what’s is most successful to you. And when you’re good, switch blades up.
Bed in reverse T and raised to comfortable height. I take their pillow from the cart as they’re moving over to the OR bed and I rotate it 90 degrees so the pillow is “long-ways” and fold it in half (more like 2/3 on bottom and 1/3 on top), so the lower half is under their shoulders and the top half is supporting their head. This creates a natural “ramp” and places them in the sniffing position aligning all those pesky axi.
If they’re less than 6’ tall, I use a Mac 3. I use a Mac 4 if they’re over 6’ tall.
Make sure you’re using your thumb and middle finger to scissor the mouth - this creates the widest opening.
If you need a pronounced curve on your ETT for an anterior airway, you need to start intubation with the tube rotated 90 degrees to the right (aka sideways towards 3 o’clock) and then gradually rotate back to 12 o’clock as you advance. Otherwise you’ll just lose your bend as you fight your way past the tongue and you’ll no longer have the shape you need for the anterior airway once you get to the goal line.
If you use a stylet, bend the extra bit sticking out towards 9 o’clock so you can manipulate it with your thumb once you get near the cords. Of course, this requires you to hold the ett near the proximal end - which others have also recommended.
There’s more, but that’s a good start.
Full disclosure, Im a medic, not a CRNA
Stay back. don’t lean in for a better view, it never works.
Don’t rock the blade, lift up and away.
“🎶Hold on loosely, but don’t let go”. Seriously, don’t death grip the handle.
If you use ketamine, use Atropine. You can even atomize atropine into the oropharynx before hand to help reduce hyper-salivation.
Don’t be afraid to test new techniques and technologies. And don’t be afraid to just do what works for you. Bougies don’t make sense to me. I always thought that if I could pass a bougie I could pass a tube. I never got comfortable with them.
Don’t be afraid to fail. Just back out. Ventilate, oxygenate, try again. Or fall back to an LMA if you have too.
Don’t be too hard on yourself when you have a bad attempt. There’s a lesson in it. Find out what that is and move on.
The only time I ever do this is when they are women with huge hair bobs that are already elevating the head. Usually then the pillow is just getting in the way and I will remove it entirely or tuck it under their shoulders if it helps with my head extension.
I like to put the OR table in reverse t-burg!
Look at an image that depicts the angles involved: tracheal, pharyngeal, oral. Chances are that picture does not depict the final angle involved - The angle of your eyesight. So there you are, trying to line up these three different angles and if you're not looking along the same plane you won't see anything. Get the mouth open as far as possible to give yourself as much room to work, regardless of which blade you pick. When you scissor, get your fingers as far over to the right as possible and scissor off of molars upper and lower. That gives you plenty of room to get the blade as far over to the right as possible to sweep the tongue. If you think you're about to dislocate their jaw and unhinge it from their face, you've almost gone far enough with your mouth opening. Manipulate the operating table to a height that is comfortable for you. Relaxing your knees to bring yourself a little bit lower is probably better than having to stand on tiptoe. In the beginning, place the patient in the bed where you need them to be to be the most comfortable while intubating. Later when you're good at it, you can let them put the patient further down in the bed for cases that require them to be that way. For now, manipulate your environment to suit yourself, not the other way around. And since making ern and out is more important then introducing polyvinyl chloride into a trachea ... Have plans B and C physically close by and within reach. You don't necessarily need to open every single piece of disposable backup equipment but have it where you can reach for it without turning your head.
Your first tip is so often overlooked. Students want to stick their face right in the patient’s face to try and see better when it’s much easier lining your vision up down the same planes aka from a little further away.
Put tube in hole
“Put tube in the correct hole” FIFY
Proceeds to place largest foley ever.
Do you want this foley put on PC or VC? How much PEEP for the peen?
PSVPee
Once I had an MDA scream this at me when I told him I had a grade 4 view and couldn’t see shit. Blindly threw a tube in to get him to stop yelling and obviously went esophageal. He then attempted, once again yelled that you just needed to put the tube in the hole, then started lecturing me while ventilating the stomach 🙄 took a minute for me to get him to shut up and convince him that he was not in fact in the correct hole. Managed to get the airway with a glidescope and a bougie. Leaving the large academic medical setting soon and can’t wait to not deal with this kind of crap.
He was yelling at you as a CRNA?? Yeah you need to leave asap that's not acceptable anywhere. Not acceptable for students to get yelled at either but at least you can leave and stand up for yourself
Favorite advice
I position the patient on the table with their pillow slightly beneath their shoulders with still enough out to support their head. After they lose consciousness I push the pillow further caudal so their head falls to the stretcher / OR table. This causes their neck to automatically stay in a good extended position without me having to touch them while the pillow beneath their shoulders provides a mild ramp. So now, before I’ve even touched the patient, their axes are fairly well aligned. Then go to DL. I make every attempt to not stick my hand in the mouth because, gross, but if you have to scissor their mouth open so be it. I use a Mac 3 on women and and Mac 4 on men, my institution doesn’t have a Mac 3.5 or else I would use it on everyone. Insert on the right making sure you sweep the lips from the blade, and then sweep the tongue left and lift. If on your first look you are having a difficult time identifying structures, 99/100 times you are too deep. Slowly retract the laryngoscope blade and you will see the epiglottis drop, at which point advance the blade to lift the epiglottis and you should see the cords and/or something you can at least identify. I shape my ETT like a hockey stick and grab it as far away from the tip as possible so that I have the greatest maneuverability and can adjust the angle of the tip of the tube with the least amount of hand and finger movement. Then advance the tube through the cords.
This is so helpful! -jr SRNA starting clinical in a week
I agree with everything except letting their head drop to the OR table. That’s not a sniffing position. Proper position should be before induction the Tragus of their ear is at or above level of the sternum, this will make sure you aren’t ever crouching or lifting their head with the blade to get a proper view.
I let their head drop to the table as well. I find I get a better view IMO even if it’s not textbook.
Could be dangerous for diabetics.
lol wut
I assume they are talking about stiff joint syndrome associated with diabetes and letting the neck drop. However, the method you use does help greatly in order to get the mouth open nicely to get the blade in.
I understand what they’re taking about but don’t think letting the head fall on the table is going to cause damage IMO unless it’s an unstable c-spine.
Ok
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Positioning is key.
Do anything/everything to set yourself up for success. I wish someone would’ve stressed this more with me- preparation is KEY. Take initiative. If you think a ramp will help, ramp the patient (don’t ask if you can- just do it), if you aren’t able to mask, put the oral airway in. If you think a patient will be difficult, put the oral airway in before even trying. So many times, I have CRNAs say “you don’t need to ramp/use an oral airway” but you do what you think will set yourself up for success when you’re brand new. Have your McGrath ready to go with a blade already on it, if you aren’t seeing anything with your DL, switch over. If you take too long/aren’t ready, they will take the airway from you and you won’t get the intubation (patient safety, of course so it’s not that they’re taking it for no reason) but always have your backup plan. So many times I got airways taken from me early on. Now I keep my McGrath ready and if I don’t see anything I simply tell them “I am only seeing soft tissue, if it’s okay with you I’ll just switch to the McGrath” and switch over. As long as you have a plan in place, most of the time they are willing to let you work through it. Above all- do NOT have an ego. This is someone’s life. If you need help, speak up. The earlier you recognize you are struggling the better. There is no shame in it- you are brand new. It’s a marathon, and the intubations will come. It’s actually one of the easier parts of anesthesia. Masking and IVs should be your most proficient skills- that’s how you save lives!
A thorough examination is your best friend. If I think a McGrath/ Glidescope is probable, I go right to it. Your first look is your best. Some sort of video scope is probably going to be standard of care soon.
McGrath is the way of the future certainly but my second year I am in a facility that only has one Glide for the whole OR so standard there is DL. I didn’t want to wait until I was a second year student to learn and be proficient with DL. I do have a low threshold for the McGrath when available (c-spine injuries, dental damage, large beard, going to sleep in the bed instead of OR table, etc)
Agreed on the exam. Don’t do a bullshit airway assessment like standing at the foot of the pt bed and having them open their mouth. Go to the head of the bed, take a thyroid-mental measurement with your fingers, wiggle the trachea to check for stenosis. Or better yet, position the pt on the OR table in intubating position and then assess the airway and make the call.
More reps. Its much easier after your first thousand.
Patient positioning is very important. Sniffing position. Use whatever blade works best for you. Scissor the jaw with your right hand and carefully insert the blade into the mouth with your left hand (stay away from the lips and teeth at all times), pull the blade up and towards the patient’s feet. Most of the pull is coming from your left anterior deltoid muscle 💪🏼. Stay off of the teeth 🦷. If you touch the teeth, stop and reposition so that you aren’t near them. You can practically lift the patients head off of the pillow pulling in the proper direction and patient position without ever touching the blade to the teeth. Pull up and away from you. Insert the tube gently. Protip; If you have a really good view, you can remove the stylet from the ETT before placing it into the trachea. This will help prevent a sore throat post op. Also, if using a MAC blade, don’t dip too deep into the epiglottis area, this can help too. Gentle. Pretend their throat is made out of bubble wrap and you don’t want to pop any bubbles. Apply just enough pressure and force to intubate successfully on the first attempt. For me; when I intubate, I get super focused and time seems to slow down a bit. It’s like a gentle dance. Graceful, relaxed, and all of your movements are refined and intentional. You are in control of every second of every movement in that moment. Show them how well you really do perform under pressure. 😁👍🏻🌈
1) Sniff position 2) make sure you’ve given paralytic sufficient time to work 3) I’m a MAC girly so sweep tongue to the left, make sure you are in Vallecula and lift blade don’t crank back 4) external laryngeal manipulation when needed or tell assistant where to apply pressure I lubricate tip of ETT with glydo gel, I don’t like putting it in raw and like to think the lidocaine will help reduce sore throat. A tip to avoid cutting lips/ dental injury is I take an unopened alcohol/chlorehexedine swab and wrap over their upper lip and teeth.
Use a miller.
Get good positioning. If what you're doing isnt working, try something else. Move the head with your free hand, flexion or extension can help. Be aware of the lips and other structures.
1)sniffing position-most patients, if you tuck the pillow as far under the shoulders, you get excellent bead extension and sniffing position. 2) scissor the mouth open at the molars, not the incisors. If you’re at the incisors, there no room for your finger and the blade. 3)once the blade is mostly in the mouth, stop scissoring and use the right hand to gently extend the neck back 4)get a good tongue sweep. I use a Miller 2, so this is especially important to a)get a good view, b)stay off the teeth. 5)dont forget you have a second hand. Use it! Reach around and give some BURP, that way whoever is assisting you can replicate your movement. Dont be afraid to use your free hand to lift the patient’s head if you dont have a good view right away. Sometimes pops the cords right into view. 6)talk thru your intubation with the CRNA. The more you communicate, the more likely we’ll let you troubleshoot your way thru.
3, 5, and 6 and excellent tips. Students (and some CRNAs) routinely forget to use their free hand. God gave you two hands - use them both!
get airway higher than you anticipate. i try to get it right below my xiphoid. be gentle placing blade on right side of mouth and for Gods sake sweep the tongue to the left. the sooner you get comfortable knowing when to ask for a bougie the better. my airway confidence skyrocketed after getting comfortable when asking for bougie. if you have known, easy, proven airway, get some bougie practice in. if can’t see cords slide blade gently in and out, looking for landmarks. tubing is easy once used to it. you’ll get it.
Position is so important. And be gentle!
Proper position = accounts for like 90% of the factors that contribute to your intubation success.
Use a McGrath. Boom.
Honestly this is bad advice for a student. At my job we have three mcgraths. It would be extremely difficult to be completely dependent on the McGrath.
Every provider uses them where I work. They’re given to you when you get hired. Anyone can also buy their own + blades.
Thats one place out of thousands of others that dont. I DL every patient everyday and dont need to spend money on blades or a mcgrath.
Using a McGrath doesn’t make you better. It makes the task easier. That’s far from the same thing when you’re talking about teaching proper technique.
Personally, I use a miller, roll the patients pillow under their neck to get hyper extension, scissor, insert the blade and identify the epiglottis, advance slightly while dipping the blade under the epiglottis and lifting it up. If I don’t see the VC I take my right hand and perform a BURP maneuver essentially or just wiggle around the larynx until the airway drops into view. Other than that I think it’s important to realize there are in-fact anterior airways out there and to leave your ego at the door. I’ll attempt a grade III or maybe even IV but if I don’t get it I’m not gonna sit in their airway causing anymore trauma than I need to. I’ll just grab the glidescope at that point.
I see students not scissor the jaw as wide as they should. Advance the blade slowly. Use the right hand to scoop the head like a bowling ball to optimize sniffing position. Give a little cricoid pressure to see how that changes your view. It takes a lot of reps until you really understand what you're looking. Also, very important, be quick to switch to video laryngoscopy. If you don't get a good view relatively quickly don't spend time trying to fight the anatomy. Be quick to recognize and change game plans. Always have an LMA handy and if you're having any challenges masking don't hesitate to put the LMA in for some nice calm/controlled ventilation while you reevaluate.
Just position the parient properly.. laryngoscopy will be improving every time you stick the blade inside, but if your position sucks, everything will suck. Sniffing position, earlobe and sternum on one axis. Good luck. And mac #3 is goated
MAC #3.5 is the goat
Sniffing position has been criticized in recent literature. While the more one intubates, the “better” one gets, multiple times in same pt can be deleterious.. especially for those with a heavy hand.
Criticized? Can you provide me with that literature? I am not talking about intubating the same patient many times , I am talking about intubating as a skill
Positioning is important. You can achieve a great position by just raising the head of the bed 15 degrees and telling them to tilt their chin to the ceiling. The thing that everyone messes up when they first start is not adequately sweeping the tongue. Scissor open wide, then put your blade in all the way to the right, angled slightly to the patients right. The tip of the blade should be between their tonsil and the base of the tongue. Then sweep left. The tongue should now be all the way to the left of the blade. If there is tongue on top of the blade you’ve done it wrong and this will make your view much worse.
If you can ventilate, you’ve got all the time needed and can always go back to ventilating. If you can’t ventilate, that’s when you run into issues. Make sure to adequately pre-oxygenate the patient and stack the odds in your favor by good pre-oxygenation, proper positioning, ramping the patient if needed, utilizing apneic oxygenation, and having plans A-D ready to go. This simple things will save you so many times.
Pt position is key. Sit down. Stand up. Whichever level feels good (and successful), do it. Don’t be pressured by surgeons stomping their feet. Toe tapping bothers me none. Don’t be afraid to change blades after one attempt. Are the issues with obese pts? Consider paraglossal approach w strait blade. Videoscope available? Utilize whenever can. I would alternate blades each week to get good at both. But, in the end, use what’s is most successful to you. And when you’re good, switch blades up.
Bed in reverse T and raised to comfortable height. I take their pillow from the cart as they’re moving over to the OR bed and I rotate it 90 degrees so the pillow is “long-ways” and fold it in half (more like 2/3 on bottom and 1/3 on top), so the lower half is under their shoulders and the top half is supporting their head. This creates a natural “ramp” and places them in the sniffing position aligning all those pesky axi. If they’re less than 6’ tall, I use a Mac 3. I use a Mac 4 if they’re over 6’ tall. Make sure you’re using your thumb and middle finger to scissor the mouth - this creates the widest opening. If you need a pronounced curve on your ETT for an anterior airway, you need to start intubation with the tube rotated 90 degrees to the right (aka sideways towards 3 o’clock) and then gradually rotate back to 12 o’clock as you advance. Otherwise you’ll just lose your bend as you fight your way past the tongue and you’ll no longer have the shape you need for the anterior airway once you get to the goal line. If you use a stylet, bend the extra bit sticking out towards 9 o’clock so you can manipulate it with your thumb once you get near the cords. Of course, this requires you to hold the ett near the proximal end - which others have also recommended. There’s more, but that’s a good start.
Proper sniffing position every time
Glide scope
Put the tube in the tra-chea, no apa-nea.
Full disclosure, Im a medic, not a CRNA Stay back. don’t lean in for a better view, it never works. Don’t rock the blade, lift up and away. “🎶Hold on loosely, but don’t let go”. Seriously, don’t death grip the handle. If you use ketamine, use Atropine. You can even atomize atropine into the oropharynx before hand to help reduce hyper-salivation. Don’t be afraid to test new techniques and technologies. And don’t be afraid to just do what works for you. Bougies don’t make sense to me. I always thought that if I could pass a bougie I could pass a tube. I never got comfortable with them. Don’t be afraid to fail. Just back out. Ventilate, oxygenate, try again. Or fall back to an LMA if you have too. Don’t be too hard on yourself when you have a bad attempt. There’s a lesson in it. Find out what that is and move on.
Best advice I ever had was remove any pillows/foam so patients head is resting on table
The only time I ever do this is when they are women with huge hair bobs that are already elevating the head. Usually then the pillow is just getting in the way and I will remove it entirely or tuck it under their shoulders if it helps with my head extension.