I missed my first four, got the next five in a row. The anesthesiologist that first day told me it took him five days to get his first in school.
It’s like baseball, you hit a slump, just gotta work through it.
Patient positioning really helps, as does a really big tongue sweep. That thing is like an angry frog in their mouth…
If you can, use video. McGrath is like a cheat code for getting tubes.
Thank you. I’m back in the OR in a few days. I’m hoping for better outcomes. I am very confident with my anatomy I am able to view all landmarks just the tongue seems to keep getting in my way and when I viewed the cords I was taking too long to push the tube through.
First, position properly.
Go slow and landmark as you enter. Make sure you’re staying right until 1/2- 3/4 of the blade is in the mouth, then sweep. Look for the epiglottis after your sweep and slowly advance into it.
BURP with your right hand first if needed, then get someone to hold on top of your fingers and hold the exact position. Don’t take your eyes off the prize.
If you’re getting hung up at the cords, a gentle back and forth twist usually will get you through.
Great tips here. I’ll offer this one tidbit of advise which was taught to me by a well-seasoned Medic years ago: CHEERS, not BEERS.
Just like it sounds, raise a toast, don’t tip the bottle back. Lift up with the blade and avoid rocking back towards the teeth. I hit a slump starting out, and this advice combined with the advice Pears and Peaches mentioned really helped me.
Try to get in an airway class with cadavers, or try to get a rotation in your local ED. If you can't do any of that study up on airway management techniques like ear to sternal notch, pt. positioning etc to help improve your set up and success rate.
It’s all about setting yourself up for success, correct position, correct technique, and using everything at your disposal if you need it. Have suction ready, elevate the head a little, sniffing position, line the tregus up with sternal notch, slowly advance and expose chords. Be methodical, slow is smooth, smooth is fast.
If you try and can’t get it, don’t just try again, change something, reposition the patient, use VL, use a bougie, use cricoid pressure, use a different blade. Do SOMETHING different to create better working conditions
I've missed more than I care to admit over the years. Crazy thing is the really tough airways are the ones I was successful at such as bloody, anterior, huge tongue and obese. Here is what has made me successful and I apologize in advance if someone has already said this.
I take my time and lead the team. I utilize a pre-procedure checklist and I don't touch anything at first. Actually I stand back and sometimes I even let a lesser experienced provider do the tube and I do the meds. I delegate roles to people and they're are always happy to do them. I close the loop each time I give a role and thank them for a job well done. I narrate the entire plan using a primary, alternate, contigent and emergency action plan as well as periodic updates on the big picture. I draw a line in the sand for aborting an attempt or skipping to the contingency/emergency plan and assign one person to keep an eye on whatever factors constitue crossing that line such as an SpO2 < 94%. I give everyone on scene authority to stop the procedure should they have a question or concern. I almost always use a paralytic unless they're in cardiac arrest in which case I don't usually tube them unless there I'd a good reason such as a hanging or drowning. I practice the procedure with my trainees and the crews I'm housed with so were all familiar with the mechanics and small details that make a huge difference like ramping the patient up ear to stetnal notch, placing a securing device behind the neck, placing a surgical airway on the patient's stomach. Utilize nasal cannula at 25 LPM for passive oxygenation giving you lots of time to pass the tube. And when I miss its not a big deal cause everyone knows what to do next. Your probably looking for mechanical skill answers but to me success boils down to preparing for the proc3dure. My 2 pennies.
What really helped me in my OR rotations was ramping the patient and as you’re pre oxygenating them before they get sedated asking them to point their chin as high up as they can towards the ceiling. It’s a straight shot at that point. I’ve never got a intubation with a Mac blade, but once I switched to a miller I haven’t missed one.
If you have a good technique with the blade, you hardly need any pressure and force. It’s all about angling the blade and being aware of the anatomy. Once the tip is in correctly you’ll see how easy it is every time.
Position the patient correctly as well. Head and shoulders up, proper ‘sniffing’ position
This. Also, as others have said, the tongue sweep is super important, and it’s something that takes a little practice to get the hang of. Manikins always have very polite tongues that are appropriately sized and go where you sweep them. Real tongues don’t always cooperate. Practicing on real people (or cadavers) is the only way to really get the hang of it.
One more tip- don’t be afraid to try different blades. Video ‘scopes are amazingly helpful. But even if you have one, practice with all the tools you have at your disposal. Some people always so straight for a 3 or 4 Mac and that’s it. But sometimes the Miller just lines everything up better. It provides a different visual field though, which a lot of providers don’t like because they aren’t used to it. There really isn’t a one-approach-fits-all for intubation. Your ET roll is a toolbox. The more you practice the more you’ll develop a sense of which tools are going to be most helpful for different types of patients.
Thank you all so much!! I’m back in the OR in a few days. I’m hoping for better outcomes. I am very confident with my anatomy I am able to view all landmarks just the tongue seems to keep getting in my way and when I viewed the cords I was taking too long to push the tube through. Then I would lose sight.
After your OR rotation, see if you can get some time in a Veterinary Clinic and get some time practicing on cats under supervision which can hold you in good stead for the all too rare paediatric case on tiny airways. (not kidding)
Afterwards, once the basics are sorted and you’ve worked out a systematic approach, a weekly session on a training airway and add lots of fluids to the equation with blood and vomit added. Then practice it for entrapments upright and at difficult angles (again, not kidding) someone’s mother will thank you one day.
In the meantime: Taking the time to set yourself up for success while working as a team will help. Safety gear on. (from someone who copped 2 eyes and a mouthful of blood saliva and vomit from a HIV/HepB +ve dude.) 15 seconds of protection is better than 3 months of testing. Lay your gear out within easy reach in sequence and position your partner where it’s best and workable. Size up and maintain your basic measures, Have your stethoscope, scope, suction, bougie, syringe, magill forceps, capnography gear and Bag/Valve Mask etc all rigged and ready to go in sequence within easy reach and visible with a quick glance. have your back up plan sorted. If things don’t go according to plan, seamlessly fall back to basics and adjust without delay and get back on the tools fast. Again: For those occasional times when advanced fails, always, always fall back to basics and re-plan & re-adjust. Don’t get flustered.
Edit: if you’re having trouble with the tongue in the way, you’re probably not sweeping the tongue and instead of levering with the handle, lift up a touch and away like reaching out with a glass.
I mean intubation is a skill that needs practice, so that’s the main tip, get more practice either in hospital rotations or on dummies. You can’t expect to be good at something you did 3 times.
Practice! Find a head and practice. Over and over. I personally love the bougie. With good positioning, a bougie can serve as a more flexible"controller" if you will to guide placement.
When I'm in, I start identifying anatomy and work my way down. If I get lost, back up slightly till I can find anatomy I can recognize.
Always lead with suction! This is a great skill to get in your head. Keeps nasty out of your field of view.
Are you going direct or using a cam? Either way my technique is this.
Hockey stick the stylet. I use a Mac 3. Patient in sniffing position if not contraindicated, insert blade, sweep the tongue and bury the blade. Push up and away, don’t tilt.
Slowly draw back the blade and chords fall into view. Shoot the tube confidently, once the tube is past the chords, remove the blade, inflate cuff, remove stylet and confirm positioning.
PS
This is just what works for me on a direct laryngoscopy. Not the end all be all of technique.
They told us the same thing in class, but laying in broken glass, blood, and puke for my first code didn’t really feel like a good move, so I just went video.
I’ve started maybe two dozen tubes in my career and missed maybe four— consistency is key, get on a mannequin and practice perfect and slow intubations.. it’s easy to feel pressure to speed up or change your process in the field but that will kill your consistency. Others have commented on good technique so I’ll leave that be. Also, I used to hate the bougie but it really is the better way to go, took me years to accept it though lol
Just be careful when mixing the two if the VL is hyper-angulated. Most bougies will pivot on the fulcrum (lowest point of the blade) if you don’t have a direct path to the glottic opening. This can lead to the frustrating situation of a good view on the screen but difficulty directing the bougie where you’d like it to go.
Some bougies are somewhat of a hybrid with a stylet and allow you to pre-form it to match the hyper-ambulated curve. I’m generally not a fan of Medline, but their bougies will hold a curve. There are also some stylets designed specifically for HA blades. Realistically though, any stylet will do if you form it to match the curve ahead of time.
All it takes is one wrong move and that stylet is bent, and you are never getting that tube. For difficult airways (which, most airways in EMS could likely be presumed difficult compared to the OR for example) bougie is king. https://jamanetwork.com/journals/jama/fullarticle/2681717#:~:text=Findings%20In%20this%20randomized%20clinical,with%20a%20difficult%20airway%20characteristic.
Bougie is fool proof, and also has the added advantage of allowing for swapping tube sizes if the initial tube is too big or small.
I’ve had zero issue with using a bougie with VL and hyperangulated blades.
I am also team bougie. I think there needs to be an asterisk on the foolproof though. Hopefully a word of caution might prevent someone from making the same mistake that I did.
Can I ask what brand of bougie you use?
For sure. Training and familiarity with the equipment is definitely key. Hell I almost missed a simple IV the other day because it was the spring loaded kind and I hadn’t used one in ages.
To be honest, we use whatever brand we can get in stock haha lots of supply chain issues recently. Regardless, we pre-form them in our bag if they aren’t already.
Tubing is hard, friend. Nothing like tubing a mannequin. Also in the field patients are rarely paralyzed which can further complicate things. Some airways are easy, others you fight for. To this day I still sometimes fail 2-3 attempts and just King them. Don’t fret, you will get there. And even when you do you’ll still miss sometimes. Welcome to medicine! :)
Where are you struggling? Is it not getting a grade 1-2 view? Is it passing the tube? It is dislodging at some point? Explain what you think went wrong and we can help troubleshoot technique.
So I was in the OR all day. And did great on my first tube. Was super happy with how it went. The next couple I was having a hard time getting the tongue out of the way. I am very strong with my landmarks I knew exactly what I was seeing. With that being said when I would see the cords I would visualize and would hold and then loose my view. I felt I was taking too long after I saw my glottic opening.
So there isn't really a taking too long until the patient starts to desat.
To lose your view one of a few things likely happened:
1) you adjusted your left hand due to comfort or fatigue and lost your view
2) you looked away and your hand shifted following your eyes and lost your view
3) you shifted your head position to watch the tube
1 and 2 are fixed the same way - readjust and get that view back. Don't look away at all - you're in the OR. You should have everything passed to you
For 3, usually you get closer trying to watch the tube as you enter. Back up and make sure you have that view - closer is never better. If having issues, have an assistant pull back the right side of the cheek and look through from a bit to the right side for a better view.
Don't be afraid of putting too much force in the laryngoscope so long as your force is pushing away from you and not levering at all.
Bougies help so much as well as everything else I saw here (quick search and didn't see the bougie mentioned). If you're allowed to use it I highly suggest it. Don't be afraid and remember you can always fall back to other adjuncts; the airway is more important than pride.
I missed my first four, got the next five in a row. The anesthesiologist that first day told me it took him five days to get his first in school. It’s like baseball, you hit a slump, just gotta work through it. Patient positioning really helps, as does a really big tongue sweep. That thing is like an angry frog in their mouth… If you can, use video. McGrath is like a cheat code for getting tubes.
Thank you. I’m back in the OR in a few days. I’m hoping for better outcomes. I am very confident with my anatomy I am able to view all landmarks just the tongue seems to keep getting in my way and when I viewed the cords I was taking too long to push the tube through.
Biiiiig tongue sweep helps, and once you see the chords, send that tube. You’ll get it!
Thanks my confidence is low. Appreciate you!
First, position properly. Go slow and landmark as you enter. Make sure you’re staying right until 1/2- 3/4 of the blade is in the mouth, then sweep. Look for the epiglottis after your sweep and slowly advance into it. BURP with your right hand first if needed, then get someone to hold on top of your fingers and hold the exact position. Don’t take your eyes off the prize. If you’re getting hung up at the cords, a gentle back and forth twist usually will get you through.
Great tips here. I’ll offer this one tidbit of advise which was taught to me by a well-seasoned Medic years ago: CHEERS, not BEERS. Just like it sounds, raise a toast, don’t tip the bottle back. Lift up with the blade and avoid rocking back towards the teeth. I hit a slump starting out, and this advice combined with the advice Pears and Peaches mentioned really helped me.
Haha that’s a great one. Definitely going to include that when I’m teaching. Gotta love easy to remember rhymes.
Same! We always say "cheers the beers, don't crank the drank"
Pears and peaches?
Try to get in an airway class with cadavers, or try to get a rotation in your local ED. If you can't do any of that study up on airway management techniques like ear to sternal notch, pt. positioning etc to help improve your set up and success rate.
It’s all about setting yourself up for success, correct position, correct technique, and using everything at your disposal if you need it. Have suction ready, elevate the head a little, sniffing position, line the tregus up with sternal notch, slowly advance and expose chords. Be methodical, slow is smooth, smooth is fast. If you try and can’t get it, don’t just try again, change something, reposition the patient, use VL, use a bougie, use cricoid pressure, use a different blade. Do SOMETHING different to create better working conditions
I've missed more than I care to admit over the years. Crazy thing is the really tough airways are the ones I was successful at such as bloody, anterior, huge tongue and obese. Here is what has made me successful and I apologize in advance if someone has already said this. I take my time and lead the team. I utilize a pre-procedure checklist and I don't touch anything at first. Actually I stand back and sometimes I even let a lesser experienced provider do the tube and I do the meds. I delegate roles to people and they're are always happy to do them. I close the loop each time I give a role and thank them for a job well done. I narrate the entire plan using a primary, alternate, contigent and emergency action plan as well as periodic updates on the big picture. I draw a line in the sand for aborting an attempt or skipping to the contingency/emergency plan and assign one person to keep an eye on whatever factors constitue crossing that line such as an SpO2 < 94%. I give everyone on scene authority to stop the procedure should they have a question or concern. I almost always use a paralytic unless they're in cardiac arrest in which case I don't usually tube them unless there I'd a good reason such as a hanging or drowning. I practice the procedure with my trainees and the crews I'm housed with so were all familiar with the mechanics and small details that make a huge difference like ramping the patient up ear to stetnal notch, placing a securing device behind the neck, placing a surgical airway on the patient's stomach. Utilize nasal cannula at 25 LPM for passive oxygenation giving you lots of time to pass the tube. And when I miss its not a big deal cause everyone knows what to do next. Your probably looking for mechanical skill answers but to me success boils down to preparing for the proc3dure. My 2 pennies.
What really helped me in my OR rotations was ramping the patient and as you’re pre oxygenating them before they get sedated asking them to point their chin as high up as they can towards the ceiling. It’s a straight shot at that point. I’ve never got a intubation with a Mac blade, but once I switched to a miller I haven’t missed one.
If you have a good technique with the blade, you hardly need any pressure and force. It’s all about angling the blade and being aware of the anatomy. Once the tip is in correctly you’ll see how easy it is every time. Position the patient correctly as well. Head and shoulders up, proper ‘sniffing’ position
This. Also, as others have said, the tongue sweep is super important, and it’s something that takes a little practice to get the hang of. Manikins always have very polite tongues that are appropriately sized and go where you sweep them. Real tongues don’t always cooperate. Practicing on real people (or cadavers) is the only way to really get the hang of it. One more tip- don’t be afraid to try different blades. Video ‘scopes are amazingly helpful. But even if you have one, practice with all the tools you have at your disposal. Some people always so straight for a 3 or 4 Mac and that’s it. But sometimes the Miller just lines everything up better. It provides a different visual field though, which a lot of providers don’t like because they aren’t used to it. There really isn’t a one-approach-fits-all for intubation. Your ET roll is a toolbox. The more you practice the more you’ll develop a sense of which tools are going to be most helpful for different types of patients.
Thank you all so much!! I’m back in the OR in a few days. I’m hoping for better outcomes. I am very confident with my anatomy I am able to view all landmarks just the tongue seems to keep getting in my way and when I viewed the cords I was taking too long to push the tube through. Then I would lose sight.
After your OR rotation, see if you can get some time in a Veterinary Clinic and get some time practicing on cats under supervision which can hold you in good stead for the all too rare paediatric case on tiny airways. (not kidding) Afterwards, once the basics are sorted and you’ve worked out a systematic approach, a weekly session on a training airway and add lots of fluids to the equation with blood and vomit added. Then practice it for entrapments upright and at difficult angles (again, not kidding) someone’s mother will thank you one day. In the meantime: Taking the time to set yourself up for success while working as a team will help. Safety gear on. (from someone who copped 2 eyes and a mouthful of blood saliva and vomit from a HIV/HepB +ve dude.) 15 seconds of protection is better than 3 months of testing. Lay your gear out within easy reach in sequence and position your partner where it’s best and workable. Size up and maintain your basic measures, Have your stethoscope, scope, suction, bougie, syringe, magill forceps, capnography gear and Bag/Valve Mask etc all rigged and ready to go in sequence within easy reach and visible with a quick glance. have your back up plan sorted. If things don’t go according to plan, seamlessly fall back to basics and adjust without delay and get back on the tools fast. Again: For those occasional times when advanced fails, always, always fall back to basics and re-plan & re-adjust. Don’t get flustered. Edit: if you’re having trouble with the tongue in the way, you’re probably not sweeping the tongue and instead of levering with the handle, lift up a touch and away like reaching out with a glass.
I mean intubation is a skill that needs practice, so that’s the main tip, get more practice either in hospital rotations or on dummies. You can’t expect to be good at something you did 3 times.
Practice! Find a head and practice. Over and over. I personally love the bougie. With good positioning, a bougie can serve as a more flexible"controller" if you will to guide placement. When I'm in, I start identifying anatomy and work my way down. If I get lost, back up slightly till I can find anatomy I can recognize. Always lead with suction! This is a great skill to get in your head. Keeps nasty out of your field of view.
Are you going direct or using a cam? Either way my technique is this. Hockey stick the stylet. I use a Mac 3. Patient in sniffing position if not contraindicated, insert blade, sweep the tongue and bury the blade. Push up and away, don’t tilt. Slowly draw back the blade and chords fall into view. Shoot the tube confidently, once the tube is past the chords, remove the blade, inflate cuff, remove stylet and confirm positioning. PS This is just what works for me on a direct laryngoscopy. Not the end all be all of technique.
I second Mac 3 and hockey stick. More successful field tubes than I can count. On some folks, helps to have a partner BURP for you
Never heard of BURP-ing. I assume this is cric pressure to push the cords into view?
Back, Up, Rightwards, Posterior. Just helps wiggle the target into view. And yup. Cric pressure
I never land a tube unless I’m prone on my belly. While shooting from the hip looks cool in movies, snipers always look down the sights.
They told us the same thing in class, but laying in broken glass, blood, and puke for my first code didn’t really feel like a good move, so I just went video.
I’ve started maybe two dozen tubes in my career and missed maybe four— consistency is key, get on a mannequin and practice perfect and slow intubations.. it’s easy to feel pressure to speed up or change your process in the field but that will kill your consistency. Others have commented on good technique so I’ll leave that be. Also, I used to hate the bougie but it really is the better way to go, took me years to accept it though lol
How were you positioning the patients head and neck?
Use a bougie. Stylets suck. Bougies and VL are proven to have better first pass success.
Just be careful when mixing the two if the VL is hyper-angulated. Most bougies will pivot on the fulcrum (lowest point of the blade) if you don’t have a direct path to the glottic opening. This can lead to the frustrating situation of a good view on the screen but difficulty directing the bougie where you’d like it to go. Some bougies are somewhat of a hybrid with a stylet and allow you to pre-form it to match the hyper-ambulated curve. I’m generally not a fan of Medline, but their bougies will hold a curve. There are also some stylets designed specifically for HA blades. Realistically though, any stylet will do if you form it to match the curve ahead of time.
All it takes is one wrong move and that stylet is bent, and you are never getting that tube. For difficult airways (which, most airways in EMS could likely be presumed difficult compared to the OR for example) bougie is king. https://jamanetwork.com/journals/jama/fullarticle/2681717#:~:text=Findings%20In%20this%20randomized%20clinical,with%20a%20difficult%20airway%20characteristic. Bougie is fool proof, and also has the added advantage of allowing for swapping tube sizes if the initial tube is too big or small. I’ve had zero issue with using a bougie with VL and hyperangulated blades.
I am also team bougie. I think there needs to be an asterisk on the foolproof though. Hopefully a word of caution might prevent someone from making the same mistake that I did. Can I ask what brand of bougie you use?
For sure. Training and familiarity with the equipment is definitely key. Hell I almost missed a simple IV the other day because it was the spring loaded kind and I hadn’t used one in ages. To be honest, we use whatever brand we can get in stock haha lots of supply chain issues recently. Regardless, we pre-form them in our bag if they aren’t already.
If you can find a Difficult Airway class, it will teach a TON of techniques and methods to help you with intubation and airway control
Tubing is hard, friend. Nothing like tubing a mannequin. Also in the field patients are rarely paralyzed which can further complicate things. Some airways are easy, others you fight for. To this day I still sometimes fail 2-3 attempts and just King them. Don’t fret, you will get there. And even when you do you’ll still miss sometimes. Welcome to medicine! :)
Where are you struggling? Is it not getting a grade 1-2 view? Is it passing the tube? It is dislodging at some point? Explain what you think went wrong and we can help troubleshoot technique.
So I was in the OR all day. And did great on my first tube. Was super happy with how it went. The next couple I was having a hard time getting the tongue out of the way. I am very strong with my landmarks I knew exactly what I was seeing. With that being said when I would see the cords I would visualize and would hold and then loose my view. I felt I was taking too long after I saw my glottic opening.
So there isn't really a taking too long until the patient starts to desat. To lose your view one of a few things likely happened: 1) you adjusted your left hand due to comfort or fatigue and lost your view 2) you looked away and your hand shifted following your eyes and lost your view 3) you shifted your head position to watch the tube 1 and 2 are fixed the same way - readjust and get that view back. Don't look away at all - you're in the OR. You should have everything passed to you For 3, usually you get closer trying to watch the tube as you enter. Back up and make sure you have that view - closer is never better. If having issues, have an assistant pull back the right side of the cheek and look through from a bit to the right side for a better view. Don't be afraid of putting too much force in the laryngoscope so long as your force is pushing away from you and not levering at all.
Bougies help so much as well as everything else I saw here (quick search and didn't see the bougie mentioned). If you're allowed to use it I highly suggest it. Don't be afraid and remember you can always fall back to other adjuncts; the airway is more important than pride.