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Bougie, Bougie, Bougie!!!!

The bougie (or tube introducer) is a very cool, inexpensive, lightweight, easy to use airway adjunct that can prove to be invaluable in certain situations.  (You can even carry it in your back pocket)  It is 60cm long, flexible with a coude tip at one end.  The length is necessary for the bougie to sit in the trachea with enough length left over to extend past the end of the endotracheal tube (ET).  The coude tip  is useful to aim the bougie anterior in the airway and to help verify placement along the tracheal rings. 

 

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Indications for use include; grade 3 airway view (epiglottis only) or minimal grade 2 (for example, aretynoids only), unable to get the ET to the airway or small glottis where it is easier to place the bougie because of its thin, flexible shape vs the stiffer, less flexible endotracheal tube. 

Technique for placement:   After placing the laryngoscope into the mouth and obtaining the best view possible of the glottis, the bougie is placed into the airway either by itself, as above or ‘preloaded’ with an ETT already in place.  Regardless of technique, it is very important that the laryngoscope is  held in place while the bougie and ET are inserted.  Soft tissue damage and bronchial rupture are possible when the blade is not used to keep tissues out of the way or if excessive force is used.

1.  By itself: 

Bougie is placed into the airway and the ETT is then placed over the bougie by an assistant.  While the laryngoscopist  maintains his/her view on the cords, the tube is advanced into the trachea while the assistant holds the tip of the bougie.  Once the tube is in, the bougie is withdrawn and verification of tracheal placement is achieved with end tidal CO2 (ETCO2).  This technique allows the laryngoscopist the most control over the direction of the bougie but is often the most difficult since the bougie can be a moving target, especially while in motion as in a helicopter or ambulance, and threading the ETT over bougie can be a challenge.

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2.  Preloaded:

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The ET is placed over the bougie with just enough of the bougie exposed at the top of the ET for the assistant to hold in place while the ET is advanced into the airway.  The laryngoscopist  holds on to both the ET and the bougie.  Visualization is the same as with other techniques and attempts should not be made if greater than a grade 4 Cormack-Lehane airway.  Once placement in the trachea is confirmed by direct visualization, the tracheal clicks or hold up, the assistant holds on to the tip of the bougie preventing it from being inadvertently advanced further and the laryngoscopist holds on to the ET tube and advances it into the airway.  As always, ETCO2 is the most important determinant of tracheal placement.

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 3. Preloaded (assisted):

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As in #2 with the one exception that the assistant holds on to the tip of the bougie and the  ET and the laryngoscopist holds on to only the bougie below the ET,  proximal to the coude tip.  This may allow the laryngoscopist to be better able to maneauver the bougie since they are not trying to hold on to both the tube and the bougie at the same time.  

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Remember, regardless of technique of insertion, a very important point to consider is that the shape is of the bougie itself is key.   Sometimes in the storing of it, the bougie can become twisted and the coude tip is only useful when it is pointed up, the direction you are trying to go.  If it is off to the side, it is going to be nearly impossible to guide it into the airway.

Confirmation by one of these techniques is essential before advancing the endotracheal tube over the bougie.

Confirmation of placement:

1. Tracheal clicks-  the coude tip with ‘click’ along the tracheal rings as it is advanced into the airway.  Generally you can feel this but if you don’t, it may be in the esophagus so keep advancing gently until.

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2. Hold up- if the bougie is in the trachea, it will stop at the carina (always be gentle, never use force).  If it is in the esophagus it will continue into the stomach where there is nothing to stop it. 

Not since sliced bread has there been as cool as an invention as the bougie.  It is great to have in your tool box and can get you out of some sticky situations.  Use with the glidescope is a little more difficult due it’s softness and flexibility but it can even be helpful at times there too. 

 

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