Microskills: Befriending the Magill's

Three times now, I've had suction fail me while intubating patients with grossly soiled airways - twice due to thick chunky vomit, and once due to the thickest cobweb of mucus I've ever seen.

In each case, the Yankauer was simply unable to hoover up the larger chunks of vegetable and other detritus.

On the first two occasions I was ultimately still successful in passing a tube into the soiled airway. But on the third occasion I wasn't. On that occasion, I was working with a very experienced Swedish anaesthetist deployed as part of a Special Operations Surgical Team, and as I was struggling to see beyond the syrupy gloop that was defeating me, he took over - and pulled a pair of Magill's forceps from one of his pockets. In its tip he had wrapped a fold of gauze, and with it he mopped up the offending mucus.

It was quick, simple, and - for the patient - probably life-saving.

Sometimes we just don't have suction, and even when we do, sometimes that suction breaks, gets clogged, or simply cannot deal with a certain size or consistency of airway debris.

I'll heavily caveat this article with the fact that I am not an anaesthetist, and there will be some (many) with strong opinions on this subject. I write this as a doctor who now semi-regularly intubates anatomically difficult airways. But despite this, until that moment, the Magill's hadn't really earned a place in the forefront of my mind when it came to first line airway equipment (or even really rescue equipment). In practice, I've barely - if ever - seen them used in an emergency department setting. And this isn't without reason: if you hunt through any core emergency medicine textbook - Tintinalli's, Rosen's, Cameron's, Dunn's - they all mention them in one of only two roles - 1) as a means of retrieving solid foreign bodies in the airway, and 2) as a means of assisting passage of the tube in nasotracheal intubation (now very uncommon).

What was their intended use? Well, to read Ivan Magill's words on the subject - the father of modern endotracheal intubation and inventor of the forceps that bear his name - he said the following in his 1920 letter to the editor where he first described them:

So that's it - their original intended purpose was grasping an endotracheal tube to guide its passage during nasotracheal intubation [1]. But as with all things, there are many ways to skin a cat, and more importantly many things you can do with the skinning knife.

Watching this particular anaesthetist mop up the thick web of secretions with a single circular motion of the wrist demonstrated to me their utility in secretion management when the nature of secretions means they aren't amenable to suction or when suction simply isn't available. Once you dive into the literature - case reports describe this exact issue - debris, clots, or other gunk that's unable to be removed by Yankauer, but is then easily removed with Magill's forceps [2].

But you wouldn't automatically think to try it unless A) you already knew it was in your arsenal of airway manoeuvres, and B) had the Magill's and gauze out and ready as part of your airway checklist.

The tips of the Magill's themselves have an inner surface that is ribbed for your practicality. With them you can pick up a regular square of gauze (7.5x7.5cm or similar), and fold it in such a way that two opposite sides of the gauze are held between the tips and the gauze becomes wrapped around it.

For some reason, a number of YouTube videos demonstrating airway foreign body removal seem to show people using an underhand grip, with the Magill's being palmed. I'm not totally certain of their rationale for this, as this seems less intuitive and harder to coordinate. If you find this works for you, then go for it, but I've personally taken to holding them overhand like in the diagram above.

Using the laryngoscope as you otherwise would to illuminate the hypopharynx, insert them with their tips closed.

Here the image shows them being used to retrieve a solid foreign body, but you can instead imagine that their tip is wrapped in a fold of gauze and is being used to collect the sticky gloop or other debris that wouldn't be amenable to retrieval by suction catheter.

Summary:

Secretions can sometimes be sticky or chunky, and sometimes suction doesn't work or isn't available. Don't rely on the Yankauer to always be there to get you out of trouble. It sucks.

The Magill's on the other hand have utility in more situations than most of us typically think of in emergency or prehospital medicine.

References:

[1] Magill IW. Appliances and preparations. Br Med J. 1920;2:670.

[2] Tamras R, Austin R, Falcon R, et al. Management of a large post-tonsillectomy thrombus obstructing the laryngeal view: a case report. Cureus. 2023;15(10):e46763.