Tongue Displacement

VentMonkey

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Curious what all people are doing with the tongue in ETI. Does it matter? Is it situational? What are some of the newer providers being taught?

I was taught sweep off from the right to give you more maneuverability with passing the ETT itself. Nowadays more seem in favor of gentle guidance down the middle while pointing out (and making mental notes of) visual landmarks.

I came across the Airway Jedi’s stuff recently and reviewed some of it. It seemed somewhat dated, however, for anyone interested it’s an excellent video and site for pointing out all of the dangers with airway management—specifically ETI.

Curious what our anesthesiologist folks on here think, and/ or do. @E tank @Carlos Danger @silver ...
 

E tank

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For DL I use the Miller 2 for adults (and Millers for kids too) exclusively so I just 'avoid' the tongue altogether by sliding the blade between the right edge of the tongue and the R lower molars. I don't even teach the curved blade because I don't think I'm good enough with that blade to be of any use to a student with it. For VL, I just go right over the tongue with the blade and displace it downward into the base of the mouth. I guess that would work with a curved DL blade too. All I got....
 

Carlos Danger

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I use curved blades pretty much exclusively. I teach newer intubators the "insert on the right side and sweep the tongue to the left" method because I think it's the easiest way to learn to control the tongue. In reality, once you have a lot of experience intubating, I think you find yourself just sliding the blade into the mouth and using it to manipulate the tongue whichever way is necessary (or easiest) for that patient. At least that's me. I usually go in pretty much midline and simultaneously sort of compress the tongue cephalic while shifting it to the left a little. I don't use straight blades often anymore but I used to use them a lot, and I don't feel like the way you move the tongue with it is all that different - again, at least not once you are really comfortable.

So in a nutshell, I don't think it matters and it is situational once you have a good idea what you are doing. Just starting out though, I think it is helpful to learn the traditional methods of manipulating the tongue.
 

NomadicMedic

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I am very used to a KingVision and the placement doesn’t allow for a sweep. You just run straight down the midline and hunt for the epiglottis. In fact, the new place I’m at uses Intubrite VL and I spent a good part of my first shift getting used to it with my ol pal, Fred da Head. That’s more of the traditional DL approach.
 

E tank

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I use curved blades pretty much exclusively. I teach newer intubators the "insert on the right side and sweep the tongue to the left" method because I think it's the easiest way to learn to control the tongue. In reality, once you have a lot of experience intubating, I think you find yourself just sliding the blade into the mouth and using it to manipulate the tongue whichever way is necessary (or easiest) for that patient. At least that's me. I usually go in pretty much midline and simultaneously sort of compress the tongue cephalic while shifting it to the left a little. I don't use straight blades often anymore but I used to use them a lot, and I don't feel like the way you move the tongue with it is all that different - again, at least not once you are really comfortable.

So in a nutshell, I don't think it matters and it is situational once you have a good idea what you are doing. Just starting out though, I think it is helpful to learn the traditional methods of manipulating the tongue.
Amen...I think the curved/straight debate is based on really hoping and believing that one is better than the other in every circumstance...but in the end it's Coke or Pepsi...DL enough with either blade and the tongue becomes invisible....there are 11 items in the complete pre-intubation airway exam and the tongue and it's relative relationship to the other 10 is but one.....
 

silver

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I use curved blades pretty much exclusively. I teach newer intubators the "insert on the right side and sweep the tongue to the left" method because I think it's the easiest way to learn to control the tongue. In reality, once you have a lot of experience intubating, I think you find yourself just sliding the blade into the mouth and using it to manipulate the tongue whichever way is necessary (or easiest) for that patient. At least that's me. I usually go in pretty much midline and simultaneously sort of compress the tongue cephalic while shifting it to the left a little. I don't use straight blades often anymore but I used to use them a lot, and I don't feel like the way you move the tongue with it is all that different - again, at least not once you are really comfortable.

So in a nutshell, I don't think it matters and it is situational once you have a good idea what you are doing. Just starting out though, I think it is helpful to learn the traditional methods of manipulating the tongue.

Agree with everything here.

I used curved to DL as well and in your standard adult mostly go midline over the tongue and shift it slightly left. For kids w/ Mac blade (so like 2-8ish, normally Miller younger ones) will actively try to go right and sweep left as the real estate is smaller. With experience you end up finding the optimal way to shift the tongue as needed in the patient in front of you almost subconsciously.

One thing I do different that someone pointed out to me is I lift the head of the patient off the bed with every DL (I love front raises at the gym).
 

StCEMT

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I almost exclusively use a McGrath X3 with the occasional DL Mac 3 thrown in. That's largely due to the fact that basically everyone I intubate has an autopulse going, although here lately terrible environments have also driven that.

I midline everyone. Sometimes girth + an autopulse band necessitates kinda rolling the blade counter clockwise in place, but I am still midlining it. The occasional tongue slips away, but thats usually due to movement from CPR.

I dont think it really matters once you settle on a set up you like. Midline with the X3 blade has worked for me on everyone from the 100lb nursing home arrest to the guy the other week who was pushing or at 300lbs. That combo is my go to every single time now. I've gotten a very solid track record with it, so I tend to not deviate very often anymore.
 
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VentMonkey

VentMonkey

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Pretty much all aligning with my train of thought and practices—situational dependence to some degree with the expected (and unexpected) variations.

Thanks all. I kind of also figured why not? There hasn’t been much in the way of helpful threads (IMO) in some time.

I sure hope someone out there realizes the value of some of the advice offered on here still. Some days I feel like it’s missed both on here, and just in general. Cheers.
 

NomadicMedic

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Pretty much all aligning with my train of thought and practices—situational dependence to some degree with the expected (and unexpected) variations.

Thanks all. I kind of also figured why not? There hasn’t been much in the way of helpful threads (IMO) in some time.

I sure hope someone out there realizes the value of some of the advice offered on here still. Some days I feel like it’s missed both on here, and just in general. Cheers.
Amen.
 

StCEMT

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For DL I use the Miller 2 for adults (and Millers for kids too) exclusively so I just 'avoid' the tongue altogether by sliding the blade between the right edge of the tongue and the R lower molars. I don't even teach the curved blade because I don't think I'm good enough with that blade to be of any use to a student with it. For VL, I just go right over the tongue with the blade and displace it downward into the base of the mouth. I guess that would work with a curved DL blade too. All I got....
Is there a patient where this way is particularly beneficial? Angioedema or some other situation?
 

Carlos Danger

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Is there a patient where this way is particularly beneficial? Angioedema or some other situation?
I believe that the technique E tank is describing is what some refer to as the "paraglossal approach" which is supposed to be useful in smaller mouth openings. Traditional thinking is that while straight blades are harder to master, using one routinely is a good practice because they are better for smaller mouth openings. Some folks dispute that, but I think there is probably some truth to it.
 

E tank

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Sorry for the busy picture...the point of it all is that a straight blade device is what ENT surgeons use to operate on the glottis/larynx....I figure if that configuration is good enough for doing surgery, it's good enough for passing a tube... The blade does go 'Paraglossal' as CD noted...
 
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Tigger

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It has been over a year since I last used DL, when using a curved blade I still make an effort to sweep the tongue left to right, though it feels like more of a pivot motion to me. With the McGrath I concentrate more on camera placement and the rest seems to fall into place.
 

DragonClaw

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I haven't ever intubated live, but we were taught BURP.

But we were also told to use Miller for pedis because aiway shape differences.

In the really stiff dummies, Millers worked better than Macs
 
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VentMonkey

VentMonkey

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Found this link on YouTube pertinent to the thread. It looks like it’s from a Difficult Airway Course.
Hm, learn something new everyday I suppose.
 

Tigger

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I haven't ever intubated live, but we were taught BURP.

But we were also told to use Miller for pedis because aiway shape differences.

In the really stiff dummies, Millers worked better than Macs
BURP/laryngeal manipulation is a different concept than tongue displacement. Your first enemy in visualization is control of the tongue, without that any manipulation of lower structures won’t have much benefit. New intubators often say “I don’t see anything I recognize” or “that’s pink mush,” and generally that is caused by not controlling the tongue, which is either pressed against or just covering the structures you are trying to recognize. Could also be that the blade is not in far enough to actually manipulate the tongue, but until that is done you aren’t really going to be able to see anything.
 

Carlos Danger

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BURP/laryngeal manipulation is a different concept than tongue displacement. Your first enemy in visualization is control of the tongue, without that any manipulation of lower structures won’t have much benefit. New intubators often say “I don’t see anything I recognize” or “that’s pink mush,” and generally that is caused by not controlling the tongue, which is either pressed against or just covering the structures you are trying to recognize. Could also be that the blade is not in far enough to actually manipulate the tongue, but until that is done you aren’t really going to be able to see anything.
In my experience, "I don't see anything that makes sense" more often than not means the blade is too deep and they are looking down the esophagus.
 
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DragonClaw

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I just saw a funny looking blade diagram that shows MSc, Miller and Hyperangulated. Has anyone heard of the last or seen it used?
 

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