# Miller vs Macintosh Laryngoscopes



## WuLabsWuTecH (Jun 11, 2008)

Hey,

I'm in my 2nd week of 4 weeks in my Basic Class and we were working on intubations today.  Everyone in my class except for one other person seems to prefer the Mac (curved) blade over the Millers.  My intructors also said they refered the Mac over the miller in all cases except C-Spine.  I seem to work better with the Miller and sometimes with the Mac blades i takes me 2 tries to successfully intubate.

Anyone have any thoughts on Miller vs. Mac?

-Wu


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## Ridryder911 (Jun 11, 2008)

Sure be very proficient in both... seriously. It should not matter which one is handed to you. Both have benefits and disadvantages. Heck, I have even used a tongue blade.. anything that can raise the epiglottis to expose the glottic opening. 

R/r 911


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## VentMedic (Jun 11, 2008)

One should be very familiar and comfortable with both blades to choose the proper one for the patient.    I usually decide after a quick LEMON assessment.   If one gets too much into the "personal preference" and uses just one style of blade, they may find it does not fit all.  I would hope the instructors have gone over why each blade is designed as it is and not just "I like that one better".   

There are also different variations in the design of the blades by several manufacturers as well.  You may also find different characteristics in the non-disposable vs the disposable that you may have to be able to adapt your technique to if given the opportunity to use them.


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## akflightmedic (Jun 11, 2008)

I like the Wisconsin...

(How many are scratching their heads now saying "the what"?)

Seriously, as stated already, be proficient in both and be able to use whatever is handed to you. There are many slight variations and they have their own unique advantages and disadvantages.

Yes, I realize I added nothing new to this topic as two of the most educated people in EMS/healthcare on this site spoke before me and they both gave you sound advice. I hate it when they do that; but they did speak properly and inform correctly.

I return to my hole now.

Cheers!


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## Ridryder911 (Jun 11, 2008)

Ahhh the old Wisconsin model...lol.. Actually, the "Grandview" is nice as well. Yes, there is such a thing. Alike, being discussed is learning the techniques on all the equipment being used. Intubation is just a skill, as Vent pointed out most studies are demonstrating poor intubation rates from lack of assessing your patient prior to intubation. 

R/r 911


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## wolfwyndd (Jun 11, 2008)

Yeah, no new information here and at the risk of adding a 'me too' post, here it is.  

I've successfully intubated with both mac and miller.  Mostly depends on the patient's condition at the time.  Lemme tell you.  Trying to intubate on a patient with throat cancer was challenging.  I failed that one with both types of blades.  Actually, we had two full time paid paramedics that failed that intubation attempt so I don't feel too bad about it.


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## MSDeltaFlt (Jun 11, 2008)

VentMedic said:


> One should be very familiar and comfortable with both blades to choose the proper one for the patient.    I usually decide after a quick LEMON assessment.   If one gets too much into the "personal preference" and uses just one style of blade, they may find it does not fit all.  I would hope the instructors have gone over why each blade is designed as it is and not just "I like that one better".
> 
> There are also different variations in the design of the blades by several manufacturers as well.  You may also find different characteristics in the non-disposable vs the disposable that you may have to be able to adapt your technique to if given the opportunity to use them.



You ain't kiddin'.  On certain patient populations a disposable Mac 4 can easily turn into a Miller 3.  Kinda hate when that happens.  The light usually sputs out.  It inhales even more extremely when faced with a Cormack & LeHane 4 airway.  Not good.

I'm usually a Mac 4 man, myself, but I like to mix it up.  Like Vent and Rid said, you need to be proficient.  Some airways, you'll need a straight blade.  Some, you'll need a curved.  You need to know when to use what, and be comfortable with either.


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## Jon (Jun 11, 2008)

Are we having a discussion on religion?

This could turn into the EMS equivalent of a Mac vs. PC (windows) vs. Linux debate 


Most providers have a preference of Mac vs. Miller... and may or may not be able to actually describe why they prefer one or the other. Additionally.. as was said, there are some specialty blades like the Grandview and ViewMax that might or might not work for you. You might need to use one or the other depending on the situation. I've found that it's a little easier with a Mac blade... but if you can't see with one, give the other a shot... you should have some practice with both.


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## Jon (Jun 11, 2008)

MSDeltaFlt said:


> ...It inhales even more extremely when faced with a Cormack & LeHane 4 airway.  Not good.




How does that scale relate to the Mallimpoti scale I was taught?


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## VentMedic (Jun 11, 2008)

wolfwyndd said:


> I've successfully intubated with both mac and miller.  Mostly depends on the patient's condition at the time.  Lemme tell you.  Trying to intubate on a patient with throat cancer was challenging.  I failed that one with both types of blades.  Actually, we had two full time paid paramedics that failed that intubation attempt so I don't feel too bad about it.



People with throat CA may have "trach only" on their medic alert bracelets or IDs.  Often the obstruction makes regular intubation impossible.  There are reasons why these patients get a laryngectomy with the stoma flapped to permanently remain open and not the usual tracheostomy.  

We also have other patients with disorders such as Wegener's Granulomatosis where nasal or oral intubation attempts can become fatal very quickly if one is not expecting the blood or stenosis in the airways.  For those patients, we may just bag or sometimes use an LMA until a surgical airway is established.   Even the LMA has to be placed with caution.    This condition is chronic and should be listed on a medic alert bracelet/ID card or the family should have some knowledge.   These patients may also have some type of Montgomery (or similar manufacturer) tube in place.  Unfortunately not all these devices have the standard 15mm adaptor.  The 15 mm  adapter off of an ETT of just a size slightly larger or smaller will adapt over the device.  Fortunately this condition is not that common.


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## MSDeltaFlt (Jun 11, 2008)

Jon said:


> How does that scale relate to the Mallimpoti scale I was taught?



Mallampati is derived from looking traight into the pt's mouth with their mouth wide open and sticking their tongue out.

Cormack & Lehane is derived during direct laryngoscopy and looking (or at least trying to look) at the four landmarks for intubation.

Grade I: Entire glittic opening and vocal cords can be seen.
Grade I: Epiglottis and posterior portion of glottic opening can be seen, with a partial view of vocal cords.
Grade III: Only epiglottis and (sometimes) posterior cartilages can be seen.
Grade IV: Neither epiglottis nor glottis can be seen.

Mallampati and Cormack & Lehane are not mutually exclusive.  Having one grade in one does not necessarily mean you'll have the same grade in the other.  There just won't be a drastic difference.  If you see a Mallampati 4, expect a Cormack & Lehane 3 or 4, not a 1 or a 2.  If you get my drift.


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## mikeylikesit (Jun 11, 2008)

Robertshaw. i use both on adult but prefer the Robertshaw on pediatrics since they are way easier to work with due to the larger comparative size of the epiglottis.


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## KEVD18 (Jun 11, 2008)

grandview blade


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## Ops Paramedic (Jun 11, 2008)

The tendency this side leans toward using the Macintosh.The option i would have been my best choice was not in the selection, ie, Macintosh for adults, and Miller for neonates, and peads, any of the two.  
That is what we generaly stick to, but anyone that can get one to visualize, will do.  You won't find a lot of adult Miller blades on our jump kits, then again, on some kits you will only find a size 4 and size 1 Macintosh, and that will have to surfice!!


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## wolfwyndd (Jun 12, 2008)

VentMedic said:


> People with throat CA may have "trach only" on their medic alert bracelets or IDs.  Often the obstruction makes regular intubation impossible.  There are reasons why these patients get a laryngectomy with the stoma flapped to permanently remain open and not the usual tracheostomy.


**smile**  I was really hoping the respiratory therapist would weigh in on this because I was really interested in your opinion.  

Unfortunately, this particular patient didn't have any kind of medic alert bracelet on and we had to find out from his wife on scene that he had throat cancer but no idea what KIND of throat cancer.  Also, unfortunately (for us and this patient), we did not, at the time, have trach's on board.  This particular incident prompted us getting a few.  Although since then we have not had an incident that would require a trach so I'm not sure if our full time paid paramedics would be able to successfully use it.  Once we actually got to the hospital (workin' him the whole way) the ED staff only worked him for another 10 minutes or so before they called it.  Two ED staff (I assume doctors, but could have been a resp. tech) also failed in their intubations before they trached him.  

Oh, and totally off topic for THIS thread.  This was one of those calls were even I was 'unprofessionally' dressed because this call came in at 7am on a Sunday morning and it was a call where the full time paid crew asked for 'any available personnel respond direct' so I was in shorts and a squad t-shirt coming from home.


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## VentMedic (Jun 12, 2008)

wolfwyndd said:


> Unfortunately, this particular patient didn't have any kind of medic alert bracelet on and we had to find out from his wife on scene that he had throat cancer but no idea what KIND of throat cancer.  Also, unfortunately (for us and this patient), we did not, at the time, have trach's on board.  This particular incident prompted us getting a few.  Although since then we have not had an incident that would require a trach so I'm not sure if our full time paid paramedics would be able to successfully use it.  Once we actually got to the hospital (workin' him the whole way) the ED staff only worked him for another 10 minutes or so before they called it.  Two ED staff (I assume doctors, but could have been a resp. tech) also failed in their intubations before they trached him.



When I hear throat or esophogeal CA, I hope for the best but prepare for the worst.  

I will first see if they are at all manageable by BLS methods like the BVM, oral or nasal airway.   That is before I before I start with intubation.  I will palpate for obvious masses and look for tongue movement or deformities. Checking jaw mobility is another factor.  If the patient has had previous surgeries or radiation therapy is also helpful to know.

I will also have, in the ED, the smallest ETT but still adequate in length, even if it is uncuffed available, if I visualize even the slightest opening in the glottic region.  This would be a last attempt in prep for a cric or percutaneous trach.  The ETT will facilitate a small bronchoscope (pedi size) to pass for a visual as the trach is done in the hospital.    Prior to all this, my preference would still be a BLS airway if at all possible, if there is slim chance of ETT placement, until a surgical opening is made.  I've seen some of these tumors bleed like a cranked out water faucet.

Most tumors are supraglottic or right at the glottic area.  Rarely are they subglottic. Thus, a trach incision will usually miss them.  The tongue may also be involved.  (sidenote: a tongue can be reconstructed from the lattissimus dorsi muscle)

This website has excellent links to give you a visual as to what prevents one from passing an ETT or even using the BVM.  
http://www.lib.uiowa.edu/hardin/md/throatcancer.html

*My disclaimer: Always talk to your medical director about any interesting or difficult cases to seek out his/her advice.  *

I have seen throat cancer at various stages of resection and treatment.  I always get a thorough report from the surgeon and anestesiologist to prevent surprises.   The creative methods it may take to ventilate a person never cease to amaze me.  As I continue to mention in my posts, there are over 300 different airway devices and I still run across some that aren't on my list.    RT is definitely a fascinating field and was a great career choice for me to broaden my education/knowledge from my Paramedic education/training.    It made me respect the "skill" of intubation as both a science and an art.


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## Epi-do (Jun 12, 2008)

When we were practicing intubations on the manaquins in class, I liked the Mmiller blade better.  After actually having the opportunity to do some intubations on people in the OR, I have found I prefer the Mac.  I can use either blade though and still get the tube.  (Of course, all of them have been in the controlled environment of the OR, and not in the field.  I know there will be times where the tube is harder than heck to get.)  I never specified a preference of blades while in the OR.  I just used whatever the doc handed me to use.


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## 1799687 (Jun 14, 2008)

basics intubating? awesome. i prefer a mac4 for most adult pts. personal preference.


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## gberg03 (Jul 8, 2008)

while in medic school, i loved using a miller on dummies, but on real pts im all about the mac so far.


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## JAM-EMT (Jul 8, 2008)

I'm proud to say i passed the Advanced Airway practical exams last night in my Basic class. =] I definitely prefer the Miller in Adults and Children, Macintosh in infants. This is only from experience on dummies though, I'm sure once i get in the field my opinion may change.


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## VentMedic (Jul 8, 2008)

JAM-EMT said:


> I'm proud to say i passed the Advanced Airway practical exams last night in my Basic class. =] I definitely prefer the Miller in Adults and Children, Macintosh in infants. This is only from experience on dummies though, I'm sure once i get in the field my opinion may change.




The straight blade is the recommended blade for infants utilizing a size 00 - 1 blade to lift or compress the base of the tongue.  A #1 Macintosh could be useful for a slightly bigger infant or one with an anomaly.  

A Macintosh blade may work on a manikin, but a real infant will be very different.   I have yet to find an infant intubation head that is even close to a real baby.   The better quality adult intubation heads do give you some idea of the procedure but several live intubations will need to be done to adequately experience the procedure and the different complexities of the human body.  

Again, I choose the appropriate blade based on the assessment of their airway.


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## Ridryder911 (Jul 8, 2008)

VentMedic said:


> A Macintosh blade may work on a manikin, but a real infant will be very different.   *I have yet to find an infant intubation head that is even close to a real baby. *The better quality adult intubation heads do give you some idea of the procedure but several live intubations will need to be done to adequately experience the procedure and the different complexities of the human body.
> 
> Again, I choose the appropriate blade based on the* assessment *of their airway.



Amen!...

R/r 911


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