Changing the blade

[NomadicMedic]

One of fall back positions that providers are taught after a failed intubation attempt is to "change the blade". I'm curious how many practitioners actually use this methodology after a failed attempt and if changing the blade is what actually lead to the successful intubation.

My thought is this; if in 100% of your field intubations you perform laryngoscopy with a Mac 4, and you have very little experience with a Miller blade, would it make any sense to change blades for your next attempt, when repositioning, a bougie and BURP really might be what's needed. I equate it to using the tools you're most familiar with. In the event of a difficult airway, you're certainly not going to choose a tool you have very little experience with and expect a positive outcome. While the argument exists that Paramedics should be prepared to intubate using whatever tool is at hand, the anecdotal evidence I found after polling my colleagues is almost unanimous, most of us have a “go to” blade and that is what we use most often.

I just discussed this with my medical director and he agrees to stick with the tool you know. However, following that discussion, I've decided that for the next 6 months, my intubations will be initially attempted with a Miller, not my standard Mac 4, so I can build confidence with the straight blade.

I'm curious about others experience with “changing the blade” following an unsuccessful intubation and how difficult it was to make the move to another blade type after having success with one particular blade.

 

[Shishkabob]

This is why they recommend utilizing different blades so that they aren't too unfamiliar with you when you need to use it. Each patients anatomy is different, and while a Mac might work on some, a Miller might provider a better view for others.



I've yet to miss a tube (knock on wood) but the one time I got less than optimal view on a patient, I switched from a Mac 3 to a Miller 3, and got a great view and sent the bougie on in.






PS-- Every intubation of mine gets a bougie. Why use it as a fall-back when it can increase your odds on the initial attempt?

 

[systemet]

PS-- Every intubation of mine gets a bougie. Why use it as a fall-back when it can increase your odds on the initial attempt?

I haven't intubated anyone in a few years (not been working in EMS), but I loved the bougie. I used to normally go with a mac blade, lubed, styleted ETT for the first attempt, and then go to a Bougie for the second, and BIAD / BVM for failures.

I also understand the argument for not using a stylet or a bougie, so that they don't become a crutch. I just don't think that I was doing enough intubations (6 - 10 / year) that it mattered. I'd rather bias for success every time.

I will admit to intubating plenty of cardiac arrests with just a tube and no stylet. But this is a different scenario to a RSI or medication-facilitated intubation.

I hear that a lot of people are now using Glidescopes. They look pretty cool. I never got a chance to use one before I left.

 

[LondonMedic]

The notes to the Difficult Airway Society's (UK) guidelines say 'consider' a change of laryngoscope.

In my mind that means that you should be familiar with a variety of blades and laryngoscopes and be thinking of which combination would be most suitable for the patient you are intubating and, once you've attempted laryngoscopy and recognised a difficult airway that you reassess your choice (and that you have the equipment available to do so) as part of Plan A.

 

[LondonMedic]

I hear that a lot of people are now using Glidescopes. They look pretty cool. I never got a chance to use one before I left.

They're quite cool but I much prefer the Pentax because it uses approximately the same technique and angles as normal laryngoscopy.

 

[usalsfyre]

You should be using a variety of blades in training and on predicted "easy" intubations to retain familiarity with them. I've had a couple of tubes where changing from a Miller 3 to a Mac 4 produced better visualization.

I'm a fan of a bougie getting used on every prehospital intubation. Call it a crutch, but even anaesthetists have been noted to achieve lower C&L scores in the prehospital environment than in the OR. So why not set yourself up for success?

 

[Smash]

There is a kind of human factors approach in dealing with a missed or difficult intubation, and one of the important things to do is to change something in your approach. Hung's book (Management of the Difficult and Failed Airway) talks about this and that it kind of doesn't matter what you change (blade, handle, bougie, whatever) as long as you take a different approach. So definitely practice with some different blades, it will give you another option.

As for the bougie, I'll toss a different perspective out there: I explicitly don't use it on every intubation as Plan A. I have a clear hierarchy of plans, from A to E for dealing with an airway gone wrong. The bougie is part of my Plan B when I strike an unexpected difficult airway, it gives me something to change, and will hopefully make my life easier (and the patient's life longer)
If I use the bougie every time, when I have an unexpectedly difficult airway that I can't get first up, I then have one less tool, one less plan, one less thing that I can change to improve my chances.

Of course, when the patient is a pregnant Asian woman with facial trauma, all bets are off!

 

[usalsfyre]

.Of course, when the patient is a pregnant Asian woman with facial trauma, all bets are off!

Let me guess, she's obese and has a VERY pronounced overbite too...

I'll go ahead and get the scalpel out.

 

[NomadicMedic]

I agree with all the points raised, however I've been extremely lucky that all of my past intubations (with the exceptions of peds) have been accomplished with a Mac 4. I've used a bougie on several occasions and have relied on changing position of both the PT and myself to align the axises and facilitate the tube. I guess my last thought is to take away the blade that I'm used to, the blade that I've had success with in the past, and replace it with a tool that I've used only to place a tube in a rubber head.

I plan on addressing this, as I mentioned I'll be using a Miller blade as my first blade in my simpler tubes. However, I'm curious as to how many intubations the experienced field providers have performed with a “secondary" blade rather than their "regular" go to blade. After asking several experienced medics, I'd hazard a guess that it's very few.

Is it a matter of developing intubation skill or simply complacency?

 

[usalsfyre]

.I plan on addressing this, as I mentioned I'll be using a Miller blade as my first blade in my simpler tubes. However, I'm curious as to how many intubations the experienced field providers have performed with a “secondary" blade rather than their "regular" go to blade. After asking several experienced medics, I'd hazard a guess that it's very few.

At least 4 in the last two years, averaging about 10 tubes a year. Granted it's only 20%, but attempt to make every 3rd tube or so the "alternative" (for me a Mac 4) blade. There's also people I've taken one look at the size of their tounge and pulled out a Mac 4.

I'd also wager I'm the exception...

 

[NomadicMedic]

At least 4 in the last two years, averaging about 10 tubes a year. Granted it's only 20%, but attempt to make every 3rd tube or so the "alternative" (for me a Mac 4) blade. There's also people I've taken one look at the size of their tounge and pulled out a Mac 4.

I'd also wager I'm the exception...

Exactly. People who do it everyday will use what they've discovered works best for that particular person's anatomy. I know an anesthesiologist that will have a particular blade on a handle, look at the patient as they come into to OR, change the blade and load a tube on a bougie, even before he opens the patient's mouth for the first look.

For most of us, averaging far less than 25 tubes a year, we tend to go with the tried and true. For me, at 10 tubes in the last year, that's gonna be a Mac 4. I want to change that, but right now, if there's a question on if it's going to be a "tough tube", the Mac 4 will be on my handle first.

But, in the same breath, I've been a black cloud at work lately, with a code on every day shift. I'm going to make a concerted effort to change it up and work on my comfort level with a straight blade.