One of the simplest and most valuable devices to help with a difficult intubation is the bougie. It is mainly used for challenging intubations where the larynx is hard to visualize but the glottic opening can be estimated from anatomical landmarks. However bougies must be used with care to avoid patient injury.

The bougie is an endotracheal introducer that is made of a braided polyester base with a resin coating. It has both flexibility and stiffness at body temperature. The standard size for intubation is 15 Fr, which is 60 cm long. There is a 10 Fr pediatric version which can be used for endotracheal tubes as small as 4 to 6mm. A bougie will retain the curvature given to it, making it very useful for anterior airways. I highly recommend that you have a bougie in the room whenever you intubate. It’s a quick and easy aide when the unexpected difficult intubation occurs. However, like so many of our tools, you you have to use it wisely or you can seriously hurt your patient.

History

Sir Robert MacIntosh, who invented the Mac laryngoscope blade, developed the original straight gum elastic bougie in 1949 to address challenges in difficult intubations. The slender, firm bougie could be inserted into the trachea first, guiding the endotracheal tube when the larynx was hard to see. Modern bougies are no longer made of gum. They feature a curved coude tip for easier intubation of an anterior larynx.

Two Bougie Techniques Depending on Availability of a Helper

Using a Helper

During laryngoscopy, insert the bougie into the larynx if visible, or aim for the area beneath the epiglottis if not.

If you can’t see the glottic opening, correct placement into the trachea is felt as “clicks” as the bougie slides over tracheal rings. You won’t feel clicks if the bougie is in the esophagus. Advance the bougie past the cricoid ring and down the trachea. The device may rotate as it encounters the main stem bronchus or stop when the smaller bronchi are reached. Never force a bougie.

Fix the bougie and laryngoscope in position. Have your helper load the ETT onto the bougie and feed it down to you until you can grab it. The helper should be gentle to prevent dislodging the bougie or hitting the laryngoscope near the teeth. Once loaded, you should gently continue to push the tube down the bougie through the mouth and into the trachea. The action is often called “railroading” the tube down the bougie – presumably because the tube is following the “track” into the target.

Verify placement.

Without a Helper

Preload the endotracheal tube onto the bougie. Slide it far enough down that you can stabilize both tube and bougie. However don’t advance so far down that it interferes with your ability to manipulate the bougie into trachea.

Once you have the bougie in the trachea slowly “railroad” the bougie as above.

Always listen for breath sounds to verify tracheal placement, especially when intubating without a good view of the glottic opening.

Should I Remove the Laryngoscope Or Not Before Advancing the tube?

Some people prefer to remove the laryngoscope before advancing the endotracheal tube down the bougie and into the trachea. The rationale for removing the scope is to makes tooth damage less likely as you are manipulating bougie and tube.

Removing the laryngoscope prior to “railroading” the tube can cause potential problems:

• More likely to twist the bougie out during tube insertion and getting an esophageal intubation
• Higher risk of advancing the bougie at the same time, risking tracheal trauma
• Higher risk of tearing the Endortracheal tube cuff against the teeth

Depending on the situation, I usually wait to remove the laryngoscope until after I have stopped advancing the endotracheal tube.

Dangerous Complications Using a Bougie Are Rare But Real

Use a bougie in combination with laryngoscopy under direct vision rather than as a blind stent. The bougie is stiff enough to cause damage or perforation of the trachea,  bronchi and potentially the esophagus. A bougie can injure other laryngeal and pharyngeal structures as well. You must use it with caution. A bougie passed through the bifurcation at the carina can cause a bilateral tension pneumothorax. Bilateral pneumothorax is particularly difficult to diagnose because:

• the trachea remains midline
• the heart remains midline, and not displaced
• the breath sounds, though poor, will often be equal

Routine endotracheal tube exchange is not recommended because of the associated risk of perforation. Use a standard tube exchanger, as it is softer, more flexible, and has a hollow lumen for oxygen delivery if needed. Exercise the same caution when advancing a tube with its cuff above the cords.

However, it is difficult to say “never” in medicine. If a tube exchanger isn’t available in a life-threatening case, using a bougie may be the best option for certain patients. If you do decide to use a bougie in this way:

• measure the distance against the outside of the patient before you start
• estimate the distance to mid-trachea
• insert the bougie only to mid trachea
• instruct an assistant to securely maintain the airway device’s position as you begin to insert the endotracheal tube. They must ensure that it does not unintentionally advance further during the procedure
• check breath sounds and be alert to hemodynamic during and after the procedure
• always be gentle

Tips For Success

When using a bougie, keep your eyes on the target. If the tube tip catches on the anterior commissure, rotate it to pass through the vocal cords. Once the tube is in place, withdraw the bougie and laryngoscope and verify correct placement of the tube.

It can be difficult to guide the bougie tip into the trachea if the patient has limited neck extension or restricted mouth opening.

My good friend, anesthesiologist Steve Blum taught me his trick. Press the shaft of the bougie lightly against the upper teeth during insertion. This forces a shallow bend that curves the bougie tip upward toward the larynx. The more you press the more it bends, helping you aim around the corner and easing insertion.

A study (1) found that 45% of patients needing cervical spine stabilization had a limited larynx view during direct laryngoscopy in the neutral position. Of these, 22% had views showing only the epiglottis. They intubated all the patients in the bougie group within 15-20 seconds. On the other hand, 5 patients in the laryngoscopy only group subsequently required the bougie and 5 required more than 50 seconds for intubation. Thus the bougie appears to be a good adjunct for difficult intubations. Practice its use in routine intubations to gain experience before you need it in an emergency.

May The Force BeWith You

Christine E. Whitten MD, author:

Anyone Can Intubate: A Step-by-Step Guide, 5th Edition
Pediatric Airway Management: A Step-by-Step Guide
Basic Airway Management: A Step-by-Step Guide

(1) Nolan, JP; Wilson, ME: Endotracheal intubation in patients with potential cervical spine injuries: An indication for the gum elastic-bougie. Anes. 1993; 49:630-633.