Bougie Living: Elevating Your Airway Skills with Bougie-Assisted Intubation Techniques
Intubation is one of the most important procedures routinely performed by emergency medicine physicians. So much so that our program considers it one of the fundamental pillars required of EM residents and a special focus in our education. It is one of the few critical actions that can prevent rapid decompensation and death when a patient’s airway is compromised. However, not all intubations are created equal. While the first line plan is often direct laryngoscopy is necessary, a true airway expert should always have multiple backup plans and make good use of adjuncts to improve the chances of a successful intubation to improve the patient’s course. One helpful adjunct that can be underutilized is the gum elastic bougie.
The bougie is a semi-rigid plastic gummy rod that can be molded to form a more useful angle to pass through the cords and subsequently allow for the tube to be passed over it and into the trachea. The benefit lies in the modifiable angle and greater total length that increases maneuverability. This is specifically useful with the difficult anatomic airway, which is most commonly caused by airway structures being located more anteriorly. If the epiglottis is unable to be adequately elevated by laryngoscopy, the bougie is an excellent choice to convert the airway into a modified Seldinger technique (i.e. entering a space with a wire and advancing a cannula over it). This would correspond to a Grade 3 Cormack-Lehane view, where the epiglottis completely occludes the cords despite manipulation by the provider and can be an indication for bougie use specifically. The bougie’s phalange at the distal tip can assist in angling the bougie into an anterior airway.
However, a common pitfall to this method is that the increased maneuverability can multiply small movements of the hands and make it difficult to accurately aim through the vocal cords. The standard “pencil grip” that is often taught is notorious for this. This grip only allows for forward movement of the bougie as opposed to elevation into an anterior airway. A modified “trident grip” using three interlocked fingers on either side of the bougie can stabilize the structure and allow for more controlled movements and a greater chance of successful intubation. The key to this grip is using the middle finger under the bougie as the lifting force to assist in overcoming the anterior airway. Similarly, the “Kiwi grip” can also be used to create greater stability but requires shortening of the bougie by doubling back. Becoming adept at all of these grips and knowing when to use them on certain difficult airways can improve intubation success and help add more tools to the airway manager’s toolkit.
Pencil grip: this is a commonly used technique which makes small operator movements at the grip into large sweeps in the airway. Best to be avoided!
Trident grip: using interlocking fingers around the bougie allows for better control of the bougie tip in the airway due to multiple axis points, and can be held back further on the device to allow the operator to keep their view while standing further back from the patient. The middle finger under the bougie is key to providing the lift to enter the anterior airway.
Kiwi grip: preloading the tube on the bougie, curling it back into a circle, and grabbing the back end with the pinky allows for a stronger foundation and better stability. Because the bougie can be more easily preloaded, it can be better when there is not an assistant. However, doubling back can shorten the device and require the operator to physically move closer to the airway.
An important final step that is the same with all of these techniques is confirming placement. This is especially important with the bougie-assisted technique, as it is often performed blind due to difficult patient anatomy. Once the bougie is believed to be through the cords, a useful sign to look for is the “Click Sign” where moving the bougie gently back and forth results in feeling a click against the tracheal rings. Absence may indicate insertion in the esophagus. A second useful sign is the “Bronchial Hold-Up” where advancing the bougie results in meeting gentle resistance as the elastic enters and becomes wedged in a bronchus. If the bougie is in the esophagus, there will not be any hold up as the bougie will advance easily through the entirety of the esophagus towards the stomach. In general, most average adults with have their carina and the splitting of their bronchi located at 30-35cm. It is important to pull back slightly from this position before intubation. Once positioning has been ensured, advance the tube over the bougie and then remove the bougie. Make sure to test for placement of the tube as with any other intubation.
Undertaking an airway is undoubtedly one of the most serious procedures in emergency medicine. Every possible effort should be made to choose the right technique and increase the chances of a successful first pass intubation. A 2018 meta-analysis of 5 RCTs demonstrated a non-significant increase in first pass intubation attempts when bougie-assisted intubation was used compared to rigid stylet-assisted intubation [1]. As the authors of that study noted, the specifics of the institution, patient population, and provider comfortability/preference likely play a greater role than any one factor. However, more specifically tailored studies have shown significant benefit to bougie use. The BEAM trial in 2018 demonstrated a significant increase in first pass intubation attempts when assisted by a bougie in emergency department patients with known difficult airway features [2]. Similarly, a recent 2021 trial in the Annals of Emergency Medicine demonstrated a significant increase in first pass intubation for out-of-hospital EMS providers operating in the field [3]. The sum total of the literature seems to indicate that while bougie use is not universally superior to traditional techniques, it can result in significantly better intubation success rates. Thus, EM physician must be comfortable skillfully using the bougie to enhance their success in overcoming the difficult airway!
POST BY: DR. DYLAN SEXTON (PGY1)
FACULTY EDITING BY: DR. MATTHEW STULL
References
Sheu YJ, Yu SW, Huang TW, Liu FL, Lin YK, Tam KW. Comparison of the efficacy of a bougie and stylet in patients with endotracheal intubation: A meta-analysis of randomized controlled trials. J Trauma Acute Care Surg. 2019 May;86(5):902-908. doi: 10.1097/TA.0000000000002216. PMID: 30741881.
Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. PMID: 29800096; PMCID: PMC6134434.
Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med. 2021 Mar;77(3):296-304. doi: 10.1016/j.annemergmed.2020.10.016. Epub 2020 Dec 17. PMID: 33342596.