The bougie: an inexpensive lifesaving airway device

Background

“Bougies,” otherwise known as endotracheal tube introducers, remain preferred devices for the emergency physician when faced with a difficult airway. Bougies have high success rates for the prehospital provider and the first-time emergency department (ED) user, with few reported complications. Inexpensive, disposable models provide simple yet valuable tools in the challenging patient with an anterior airway or limited neck mobility.

Objectives

Use of the bougie is similar to standard endotracheal intubation. Correct placement is determined by feeling “clicks” as the device passes over the tracheal rings and a “hold up” when entering the distal airways.

Case Reports

Three recent cases from our ED are briefly reported, in which the bougie was invaluable in the management of the difficult airway. All patients had limited visualization of the glottis but were intubated successfully.

Conclusion

This article discusses three example cases, and then reviews the history of the bougie, placement technique, and current evidence for use.     

A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: A manikin study

Background

Insertion of a supraglottic airway and tracheal intubation through it may be indicated in resuscitation scenarios where conventional laryngoscopy fails. Various supraglottic devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), the Ctrach™ laryngeal mask and the I-gel supraglottic airway.

Methods

A prospective study with 25 participants evaluated the success rate of blind intubation (using a gum-elastic bougie, an Aintree intubating catheter (AIC) and designated tracheal tube) and fibrescope-guided tracheal intubation (through the intubating laryngeal mask airway and the I-gel supraglottic airway) on three different airway manikins.

Results

Twenty-five anaesthetists performed three intubations with each method on each of three manikins. The success rate of the fibrescope-guided technique was significantly higher than blind attempts (P < 0.0001) with both devices. For fibreoptic techniques, there was no difference found between the ILMA and I-gel (P > 0.05). All blind techniques were significantly more successful in the ILMA group compared to the I-gel (P < 0.0001 for bougie, Aintree catheter and tracheal tube, respectively).

Conclusions

The results of this study show that, in manikins, fibreoptic intubation through both ILMA and I-gel is a highly successful technique. Blind intubation through the I-gel showed a low success rate and should not be attempted.     

Use of the intubating laryngeal mask airway in pre-hospital care: a case report.

In trauma management, the importance of early and effective control of the airway is acknowledged universally. Attention to the airway is particularly vital when a casualty has sustained serious head or facial injuries. A cuffed tracheal tube has generally been regarded as the airway adjunct of choice in such cases. However, the attempted insertion of a tracheal tube under direct laryngoscopy is associated with a number of practical problems in pre-hospital trauma care. A case is described in which the intubating laryngeal mask airway (ILMA or LMA-Fastrach) was used successfully in the pre-hospital setting to secure the airway of a patient who had sustained serious head and facial injuries in a road traffic collision. The indications for the use of the ILMA in pre-hospital care are discussed.     

New airways for resuscitation?

Over the last 15 years supraglottic airway devices (SADs), most notably the classic laryngeal mask airway (LMA) have revolutionised airway management in anaesthesia. In contrast for resuscitation, both in and outside hospital, facemask ventilation and tracheal intubation remain the mainstays of airway management. However there is evidence that both these techniques have complications and are often poorly performed by inexperienced personnel. Tracheal intubation also has the potential to cause serious harm or death through unrecognised oesophageal intubation. SADs may have a role in airway management for resuscitation as first responder devices, rescue devices or for use during patient extraction. In particular they may be beneficial as the level of skill required to use the device safely may be less than for the tracheal tube. Concerns have been expressed over the ability to ventilate the lungs successfully and also the risk of aspiration with SADs. The only SADs recommended by ILCOR in its current guidance are the classic LMA and combitube. Several SADs have recently been introduced with claims that ventilation and airway protection is improved. This pragmatic review examines recent developments in SAD technology and the relevance of this to the potential for using SADs during resuscitation. In addition to examining research directly related to resuscitation both on bench models and in patients the review also examines evidence from anaesthetic practice. SADS discussed include the classic, intubating and Proseal LMAs, the combitube, the laryngeal tube, laryngeal tube sonda mark I and II and single use laryngeal masks.     

Out of hospital difficult intubation resolved with nasotracheal use of a gum elastic bougie

We report the case of a 30 year old man managed in an out of hospital setting for a cardiorespiratory arrest. The patient was impossible to intubate under direct laryngoscopy because of a severe mouth opening limitation associated with a buffalo neck. After failure of direct laryngoscopy and intubating laryngeal mask airway, an Eschmann tracheal tube introducer (gum elastic bougie) was introduced through a nostril. The bougie could be blindly inserted into the trachea, and the patient was intubated using the bougie as a guide. Tracheal intubation was then confirmed using the syringe aspiration test and end tidal carbon dioxide detection.     

An Unanticipated Complication of a Novel Approach to Airway Management

Background: The King LT (King Systems Corporation, Noblesville, IN) is a rescue airway device that is gaining favor in the pre-hospital setting. Unlike other rescue airway devices, such as intubating laryngeal mask airways, the King LT does not allow for the placement of an endotracheal tube through the device. Emergency physicians who receive patients with the King LT in place will be presented with the challenge of converting to a definitive airway. Methods: We attempted a strategy that would allow for conversion from the King LT to the endotracheal tube using a gum elastic bougie. During an airway skills maintenance session utilizing non-embalmed cadavers, Emergency Medicine faculty attempted to convert a King LT to an endotracheal tube using a gum elastic bougie. Results: The technique was not successful, and in fact, resulted in an unanticipated complication. Conclusion: We cannot recommend using the gum elastic bougie as an aid to convert the King LT to an endotracheal intubation based on our experience with a non-embalmed cadaver.     

Comparison of intubation performance by junior emergency department doctors using gum elastic bougie versus stylet reinforced endotracheal tube insertion techniques

Objective: Endotracheal intubation is a challenging procedure in emergency medicine. Junior doctors lack experience and confidence in this task. The use of a gum elastic bougie (GEB) to facilitate intubation may improve success rates, especially in difficult situations. Methods: Junior doctors working in the ED were studied. Endotracheal intubation was simulated using part‐task trainers in “easy” positioning and “difficult” positioning modes. Intubation was attempted in both positions using either an endotracheal tube, with re‐inforcing stylet (ETT‐S), or insertion of a gum elastic bougie (GEB), with subsequent passage of the endotracheal tube over the bougie. Success rates and time to complete intubation were measured with GEB, and with ETT‐S. Participants were asked to record the perceived ease of intubation. Results: One hundred and four intubations were performed by 26 study subjects. Overall, mean time to intubation with ETT‐S technique was 16.14 s (14.49–17.98 95% CI), and was faster than with GEB 24.18 (21.45–27.25 95% CI) in both airway difficulty grades (P < 0.01). The success rate for intubation using the GEB was 100%, compared with 92.9% with ETT‐S. This difference was not statistically significant. Perceived ease of intubation was similar for GEB and ETT‐S (VAS 6.808 vs 6.904). Conclusion: The use of a GEB marginally increases the time taken to perform endotracheal intubation. Success rates for junior doctors attempting endotracheal intubation were not significantly different between the two techniques. Success rates for novice practitioners using a GEB were high after even limited instruction and practice.     

The difficult airway in the emergency department

Background

The patient with difficult airways is a common challenge for emergency physicians.

Aims

Our goal was to study the reasons for difficult airways in the emergency department.

Methods

We performed a prospective observational study of patients requiring advanced airway management from 1 January 2000 to 31 December 2006.

Results

There were 2,343 patients who received advanced airway management of which 93 (4.0%) were deemed difficult. The main diagnoses were cardiac arrest (28), trauma (27) and congestive heart failure (10). The main reasons for the difficult airways were attributed to an anterior larynx (38, 40.9%), neck immobility (22, 23.7%) as well as the presence of secretions and blood (14, 15.1%). The mean number of attempts at intubation was 3.6 versus 1.2 for all cases. The mortality rate of 40.5% among patients with difficult airways was not different from that of all patients who had airway management (41%). There were seven (0.3%) failed airways. Anaesthetists performed 21 (22.6%) of the rescue airways while surgeons performed 5 (5.4%). Of the rescue strategies performed, 24 were through the use of the bougie, 3 by cricothyroidotomy, 4 by tracheostomy, 6 with the GlideScope and 3 with the laryngeal mask airway. The rest the airways were secured by tracheal intubation using the laryngoscope.

Conclusions

Emergency physicians manage most of the difficult airways successfully (68.8%). However, the success rate can be further improved through the more frequent use of the bougie or other rescue device. A possible suggestion would be for the emergency physician to use the bougie after the second or third attempt at direct orotracheal intubation.     

Stylet Bend Angles and Tracheal Tube Passage Using a Straight-to-cuff Shape

Objectives
Malleable stylets improve maneuverability and control during tube insertion, but after passage through the vocal cords the stiffened tracheal tube may impinge on the tracheal rings, preventing passage. The goal of this study was to assess insertion difficulty with styletted tubes of different bend angles.
Methods
Tube passage was assessed with four different bend angles (25°, 35°, 45°, and 60°) using straight-to-cuff–shaped tubes. In two separate airway procedure classes, 16 operators in each class (32 total) placed randomly ordered styletted tubes of the different angles into eight cadavers (16 total). Operators subjectively graded the ease of tube passage as no resistance, some resistance, or impossible to advance.
Results
No resistance was reported in 69.1% (177/256) at 25°, in 63.7% (163/256) at 35°, in 39.4% (101/256) at 45°, and in 8.9% (22/256) at 60°. Tube passage was impossible in 2.3% of insertions (6/256) at 25°, in 3.5% (9/256) at 35°, in 11.3% (29/256) at 45°, and in 53.9% (138/256) at 60°. The odds ratios of impossible tube passage for 35°, 45°, and 60° vs. 25° were 1.52 (95% confidence interval [CI] = 0.55 to 4.16), 5.32 (95% CI = 2.22 to 12.71), and 48.72 (95% CI = 21.35 to 111.03), respectively.
Conclusions
Bend angles beyond 35° with straight-to-cuff styletted tracheal tubes increase the risk of difficult and impossible tube passage into the trachea. The authors did not compare different stylet stopping points, stylets of different stiffness, or tracheal tubes with different tip designs, all variables that can affect tube passage.     

Selective bilateral bronchial intubation for large, acquired tracheoesophageal fistula

The anesthetic management of patients undergoing tracheoesophageal fistula repair often involves lung separation, usually selective bronchial intubation with a double-lumen endotracheal tube. However, in patients with airway fistulas arising below the tracheal lumen, selective lung ventilation and separation may require unusual methods of airway management. In the patient described in this report, the airway fistulas involved the distal 3 cm of the trachea, approximately half of the left main bronchus 1.5 cm beyond the carina, and the proximal 0.5 cm of the right main bronchus. To separate and ventilate the lungs during the repair of these large and complex airway fistulas, 2 individual Mallinckrodt microlaryngeal endotracheal tubes were used. While lung separation was achieved, contrary to previous reports, the Mallinckrodt's larger and more tapered cuff made positioning in the left main bronchus an ongoing issue that required the use of a conventional endotracheal tube and, eventually, intubation of the bronchus from the surgical field. Future cases involving complex airway fistulas should consider endotracheal tube limitations and other methods of providing ventilation such as high-frequency jet ventilation or cardiopulmonary bypass.     

Frova intubating catheter position can be determined with aspirating oesophageal detection device

Objective: Intubating catheters (e.g. gum‐elastic bougie) are an invaluable adjunct in the management of a difficult airway. Traditional tactile ‘click’ (from tracheal rings) and ‘hold up’ (from carina or bronchus) techniques for confirming tracheal placement are, however, fallible, and definitive placement can only be confirmed following passage of the endotracheal tube. Ensuing delays might contribute to the development of arterial hypoxaemia. Our aim was to determine whether an aspirating oesophageal detector device might be useful for confirming placement of the Frova intubating catheter (a hollow‐bore intubating catheter). Method: Eighteen adult patients (American Society of Anaesthiology category 1–2) undergoing elective surgery had the Frova intubating catheter alternately placed in the trachea, or oesophagus, following induction of anaesthesia. Catheter position was assessed using an aspirating oesophageal detector device prior to tracheal intubation. Results: The oesophageal detector device correctly predicted tracheal (n = 18) and oesophageal (n = 18) placement in all patients. All procedures were completed in less than 15 s. Conclusion: In the operating theatre setting the aspirating oesophageal detector device reliably predicts tracheal and oesophageal placement of the Frova intubating catheter.     

Thoracotomy for tracheal disruption after traumatic intubation: a case report

Tracheal dissection is an uncommon complication of endotracheal intubation. A large source of morbidity and mortality in anesthesia is associated with airway issues. Several airway complications can be avoided or minimized by proper technique and vigilance. Emergency thoracotomy surgery is required in patients who suffer lower tracheal trauma. A tracheal tear poses additional challenges to traditional airway management, demanding vigilant planning and collaboration among the entire operative team. This case report details the airway management strategies employed during an emergent thoracotomy for a patient who suffered tracheal perforation during endotracheal intubation. A discussion of airway anatomy, airway considerations, intubation complications, and one-lung ventilation techniques is provided. Airway management techniques for one-lung ventilation are highly variable, requiring an extensive knowledge of equipment, clinical implications, and technical challenges. It is important for clinicians to be skilled in the use of several airway devices and to be prepared for any unexpected situation such as the case being presented.     

Recent advances in airway management

New techniques and equipment have been discovered, or rediscovered, to assist with airway management. These advances have been suggested for both field and Emergency Department use. We will review these techniques, including dual-lumen airway devices, percutaneous tracheal cannula kits, and nonvisualized methods of tracheal intubation. The last discussion will focus on tactile, transillumination, and retrograde techniques.     

Airway management in trauma: an update

This article reviews the more recent theoretic and practical information that pertains to airway management in the trauma setting. This is followed by a presentation of the newer airway devices that may be advantageous in the management of the airway in trauma as well as a discussion of other devices, techniques, or maneuvers that are useful in the trauma setting but may be underused. Each clinician needs to be knowledgeable about the various airway options and then, based on one's own particular skills and resources, construct an airway management algorithm that works best for him or her. Each clinician needs to be knowledgeable about the various airway options, and then, based on the clinician's particular skills and resources, construct an airway management algorithm that works best.     

P ARAMEDIC U SE OF E NDOTRACHEAL T UBE I NTRODUCERS FOR THE D IFFICULT A IRWAY

Objective. To evaluate the ability of paramedics to learn and apply the skill of introducer-aided oral intubation in the setting of the simulated “difficult airway.” The authors hypothesized that, following a brief introduction to the device, intubation success rates would not differ for traditional and introducer-aided intubations of an immobilized airway mannequin. Methods. During a paramedic recertification class, experienced paramedics were given a brief didactic introduction to the “bougie-like” Flex Guide endotracheal tube introducer (ETTI). The participants were then asked to intubate adult mannequins immobilized in the head-neutral position, with and without the ETTI. “Successful placement” was defined as completion of the procedure within 30 seconds and endotracheal tube position confirmed by the investigator with direct visualization. Results. For both traditional and ETTI intubations, 34 (97%) of the 35 paramedics successfully intubated within 30 seconds. The two unsuccessful intubation attempts were recognized by the paramedic as esophageal intubations, and correct tube placement was obtained within an additional 30 seconds. Conclusion. In this study, use of the ETTI was mastered by the participants after only a brief didactic introduction to the device, with their ability to intubate an immobilized mannequin using the ETTI being equal to their ability to perform traditional intubation. These results suggest that use of the ETTI is easily learned, and may support the device's role in the prehospital management of the difficult airway.     

The intubating laryngeal-mask airway may be an ideal device for airway control in the rural trauma patient

A review of the literature on advanced airway management indicates that the intubating laryngeal-mask airway (ILMA) may be an ideal device for airway control in the rural trauma patient. The ILMA is an advanced laryngeal-mask airway designed to allow oxygenation of the unconscious patient as well as blind tracheal intubation with an endotracheal tube. The ILMA is an easy-to-use airway with a high success rate of insertion, and requires little training. For the rural physician managing a difficult airway in a trauma patient, the ILMA has been found to be reliable and successful when other techniques fail, such as fiberoptic intubation and direct laryngoscopy. The ILMA has also been reported to cause less hemodynamic change and less injury to the teeth and lips than direct laryngoscopy. Further, the ILMA was found to be easier and faster to use with a higher success rate than either the combitube or endotracheal tube for unskilled healthcare providers. Limitations and complications of the ILMA may include aspiration, esophageal intubation, damage to the larynx or other tissues during blind passage of a tracheal tube, and edema of the epiglottis.     

Evaluation of an electronic esophageal detector device in patients with morbid obesity and pulmonary failure

Objective. Undetected esophageal intubation can result in permanent injury or death. Clinical confirmation of tube location may be misleading. Adjunctive methods should be used to supplement clinical judgment. Unfortunately, end-tidal carbon dioxide may misidentify properly placed tracheal tubes in low perfusion situations, while esophageal detector devices (EDDs) may misidentify properly placed tracheal tubes in situations where little airway dead space exists (morbid obesity, pulmonary failure). This study evaluated a modified EDD (the electronic esophageal detector device, or EEDD) designed to eliminate the problem of misidentified tracheal intubations. Methods. Intubated morbidly obese or pulmonary failure patients were eligible for study entry. All endotracheal tubes (ETTs) were confirmed to be tracheal by waveform capnography and clinical judgment prior to study entry. Following consent, all patients were attached to the EEDD and a “measurement” was made to determine the “location” of their ETTs. Probability of misidentifying a tracheal intubation in these high-risk populations was calculated using a log-normal distribution method. Results. Twenty-seven morbidly obese patients and 37 pulmonary failure patients were entered. The EEDD correctly identified all tracheal intubations in these patients, giving a false-negative rate of zero. The probability of misidentifying a tracheal intubation in the combined group was 0.06%. Conclusion. This study demonstrates that the EEDD reliably identifies tracheal intubations in situations where standard EDDs may fail. However, future studies must determine the reliability of this device for identification of esophageal intubations and the reliability of this device in the less controlled emergency department and prehospital settings. PREHOSPITAL EMERGENCY CARE 2002;6:59-64     

Emergency cricothyrotomy in morbid obesity: comparing the bougie-guided and traditional techniques in a live animal model

BackgroundCricothyrotomy is a rare, time sensitive procedure that is more challenging to perform when anatomical landmarks are not easily palpated before the initial incision. There is a paucity of literature describing the optimal technique for cricothyrotomy in patients with impalpable airway structures, such as in morbid obesity. In this study, we used a live sheep model of morbid obesity to compare the effectiveness of two common cricothyrotomy techniques.MethodsWe randomly assigned emergency medicine residents to perform one of two cricothyrotomy techniques on a live anesthetized sheep. To simulate the anterior soft tissue neck thickness of an adult with morbid obesity we injected 120 mL of a mixture of autologous blood and saline into the anterior neck of the sheep. The traditional technique (as described in the New England Journal Video titled “Cricothyroidotomy”) used a Shiley tracheostomy tube and no bougie, and the bougie-guided technique used a bougie and a standard endotracheal tube. The primary outcome was the total procedure time; the secondary outcome was first attempt success.Results23 residents were included, 11 assigned to the bougie-guided technique and 12 to the traditional technique. After injection of blood and saline, the median depth from skin to cricothyroid membrane was 3.0 cm (IQR 2.5–3.4 cm). The median time for the bougie technique was 118 s (IQR 77–200 s) compared to 183 s (IQR 134–270 s) for the traditional technique (median difference 62 s, 95% CI 10–144 s). Success on the first attempt occurred in 7/11 (64%) in the bougie group and 6/12 (50%) in the traditional technique group.ConclusionIn this study, which simulated morbid obesity on a living animal model complete with active hemorrhage and time pressure caused by extubation before the procedure, the bougie-guided technique was faster than the traditional technique using a tracheostomy tube without a bougie.     

The esophageal obturator airway--a review.

The esophageal obturator airway (EOA) was introduced for clinical use in 1973. There have been few controlled studies on its effectiveness or safety; those published had differing results--one showed no clinically significant difference in PaO2 and PaCO2 between EOA and tracheal tube, while two others reported slightly increased PaCO2. Subsequent modifications include the esophageal pharyngeal airway, esophageal gastric tube airway, and Vermont, or Pilcher, model. The EOA is indicated in the apneic or deeply unconscious patient. It is contra-indicated in the conscious or semiconscious patient, in children, for more than 1-2 hours, and in known cases of esophageal trauma or pathology. The most commonly reported hazard is esophageal perforation; others include tracheal intubation (which is actually the most common hazard), failure to seal mask, failure to pass tube, incorrect assembly of mask and tube, the tube's becoming an intragastric foreign body, and obstruction to intubation. While the tube is not the hazard-free device it was once thought to be, it has a place in emergency airway management in preventing insufflation of air into the stomach as well as aspiration of gastric contents.