Bougie: Difference between revisions

 
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==Overview==
==Overview==
* First described by Macintosh in 1949 (was originally using a urinary catheter)
[[File:PMC4530924 wjem-16-588-g001.png|thumb|"Preloaded" bougie setup.]]
* Modern form introduced in 1970's as Eschmann Endotracheal  
*First described by Macintosh in 1949<ref>Macintosh RR: An aid to oral intubation (letter). BMJ 1949; 1:28</ref>
Introducer
*Modern form introduced in 1970's as Eschmann Endotracheal Introducer
* Made of polyester threads and outer resin layer
**It is neither ''gum'', nor ''elastic'' nor a ''bougie''<ref>Mohammad I. El-Orbany, M Ramez Salem, Ninos J. Joseph; The Eschmann Tracheal Tube Introducer Is Not Gum, Elastic, or a Bougie. Anesthesiology 2004; 101:1240</ref>
* Typically 60 cm, malleable, and with 60 degree angulated ''coude'' tip
*Made of polyester threads and outer resin layer
*Typically 60 cm, malleable, and with 60 degree angulated ''coudé'' tip


==Benefits and Applications==
==Benefits and Applications==
* BEAM trial showed 98% FPS using compared to 87% using stylet for [[Intubation|intubation]]
*BEAM trial showed 98% first-pass success using a bougie compared to 87% using stylet for [[Intubation|intubation]].<ref>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.</ref>
* Given smaller diameter compared to ETT, allows for increased visualization when passing through vocal cords
*Smaller diameter allows for increased visualization when passing through vocal cords
* Can use "tracheal clicks" and "hold-up signs for tactile confirmation of correct placement
*"Tracheal clicks" and "hold-up" signs for tactile confirmation of correct placement
* Especially helpful with Cormack-Lehane views II-IV (can be passed blind and placement confirmed with tactile feedback)
*Especially helpful with Cormack-Lehane views II-IV (can be passed blind and placement confirmed with tactile feedback)
* Used in "scalpel-bougie-tube" cricothyrotomy technique
*Used in "scalpel-bougie-tube" [[Surgical cricothyrotomy|cricothyrotomy]] technique
* Can assist [[Blind Digital Intubation|blind digital intubation]]
*Can assist [[Blind Digital Intubation|blind digital intubation]]
* Can rotate 90° CW or CWW to selectively intubate non-bleeding lung in cases of massive hemoptysis
*Can rotate 90° CW or CWW to selectively intubate non-bleeding lung in cases of massive [[hemoptysis]]<ref>Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. Am J Emerg Med. 2016 Dec;34(12):2408-2410. doi: 10.1016/j.ajem.2016.08.057. Epub 2016 Aug 27. PMID: 27614374.</ref>
* Compatible with Macintosh blade and standard geometry video larygoscopes
*Compatible with Macintosh blade and standard geometry [[Video laryngoscopy|video larygoscopes]]


==Complications==
==Complications==
* Theoretical risk of pneumothorax with hold-up sign
* Theoretical risk of [[pneumothorax]] with hold-up sign
* Case reports of airway trauma secondary to bougie use
* No high-quality evidence to suggest bougie use leads to increased mechanical complications of intubation<ref>Hodzovic I, Latto IP, Henderson JJ. Bougie trauma--what trauma? Anaesthesia. 2003 Feb;58(2):192-3. doi: 10.1046/j.1365-2044.2003.03005_16.x. PMID: 12562428.</ref>
* However, there is no high-quality evidence to suggest bougie use leads to increased mechanical complications of intubation
** BEAM trial showed no difference in incidence of airway trauma between bougie and stylet groups


==Procedure==
==Procedure==
* Obtain view with Mac blade laryngoscope ([[Direct laryngoscopy|direct]] or [[Video Laryngoscopy|video]])
[[File:PMC4530924 wjem-16-588-g002.png|thumb|Emergency intubator demonstrating preloaded bougie technique on a mannequin.]]
* Obtain view with Mac blade laryngoscope ([[Direct laryngoscopy|direct]] or "standard-geometry" [[Video Laryngoscopy|video]])
* Pass bougie - confirm with tracheal clicks and/or hold up sign
* Pass bougie - confirm with tracheal clicks and/or hold up sign
* Have assistant "railroad" tube over bougie
* Have assistant "railroad" tube over bougie
* Alternatively can use preload ETT over bougie for single-operator using "kiwi" grip
* Alternatively can use preloaded ETT over bougie for single-operator using "kiwi" grip


==Pitfalls==
==Pitfalls==
[[File:BEAM-Trouble-Shooting-1024x645.png|thumb|Source: rebelem.com]]
* Removing laryngoscope before railroading ETT can cause difficulty in passing the tube
* Removing laryngoscope before railroading ETT can cause difficulty in passing the tube
* If resistance is met, bevel is abutting the posterior cartilages, retract the tube 1-2 cm and rotate 90° CCW, then advance tube
* If resistance is met, retract tube 1-2 cm and rotate 90° CCW, then advance tube
 
==External Links==
https://vimeo.com/1085978
 
https://prehospitalmed.com/2016/04/14/bougie-intubation-with-the-kiwi-grip/


==See Also==
==See Also==
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**[[Deterioration after intubation]] (DOPE)
**[[Deterioration after intubation]] (DOPE)


==References==
==External Links==
1. 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.
*[https://www.acepnow.com/article/the-bougie-as-an-airway-savior/ ACEPNow: The Bougie as an Airway Savior]
 
*[https://vimeo.com/1085978 Video: The Bougie]


2. Macintosh RR: An aid to oral intubation (letter). BMJ 1949; 1:28
*[https://prehospitalmed.com/2016/04/14/bougie-intubation-with-the-kiwi-grip/ Kiwi Grip]


3. Mohammad I. El-Orbany, M Ramez Salem, Ninos J. Joseph; The Eschmann Tracheal Tube Introducer Is Not Gum, Elastic, or a Bougie. Anesthesiology 2004; 101:1240
*[https://rebelem.com/bougie-use-in-emergency-airway-management-beam/ REBEL EM: BEAM Trial]


4. Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. Am J Emerg Med. 2016 Dec;34(12):2408-2410. doi: 10.1016/j.ajem.2016.08.057. Epub 2016 Aug 27. PMID: 27614374.
*[https://criticalcarenow.com/bougie-bonanza/ CriticalCareNow: Bougie Bonanza]


5. Hodzovic I, Latto IP, Henderson JJ. Bougie trauma--what trauma? Anaesthesia. 2003 Feb;58(2):192-3. doi: 10.1046/j.1365-2044.2003.03005_16.x. PMID: 12562428.
==References==


[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Critical Care]]

Latest revision as of 09:35, 3 January 2022

Overview

"Preloaded" bougie setup.
  • First described by Macintosh in 1949[1]
  • Modern form introduced in 1970's as Eschmann Endotracheal Introducer
    • It is neither gum, nor elastic nor a bougie[2]
  • Made of polyester threads and outer resin layer
  • Typically 60 cm, malleable, and with 60 degree angulated coudé tip

Benefits and Applications

  • BEAM trial showed 98% first-pass success using a bougie compared to 87% using stylet for intubation.[3]
  • Smaller diameter allows for increased visualization when passing through vocal cords
  • "Tracheal clicks" and "hold-up" signs for tactile confirmation of correct placement
  • Especially helpful with Cormack-Lehane views II-IV (can be passed blind and placement confirmed with tactile feedback)
  • Used in "scalpel-bougie-tube" cricothyrotomy technique
  • Can assist blind digital intubation
  • Can rotate 90° CW or CWW to selectively intubate non-bleeding lung in cases of massive hemoptysis[4]
  • Compatible with Macintosh blade and standard geometry video larygoscopes

Complications

  • Theoretical risk of pneumothorax with hold-up sign
  • No high-quality evidence to suggest bougie use leads to increased mechanical complications of intubation[5]
    • BEAM trial showed no difference in incidence of airway trauma between bougie and stylet groups

Procedure

Emergency intubator demonstrating preloaded bougie technique on a mannequin.
  • Obtain view with Mac blade laryngoscope (direct or "standard-geometry" video)
  • Pass bougie - confirm with tracheal clicks and/or hold up sign
  • Have assistant "railroad" tube over bougie
  • Alternatively can use preloaded ETT over bougie for single-operator using "kiwi" grip

Pitfalls

Source: rebelem.com
  • Removing laryngoscope before railroading ETT can cause difficulty in passing the tube
  • If resistance is met, retract tube 1-2 cm and rotate 90° CCW, then advance tube

See Also

Airway Pages

External Links

References

  1. Macintosh RR: An aid to oral intubation (letter). BMJ 1949; 1:28
  2. Mohammad I. El-Orbany, M Ramez Salem, Ninos J. Joseph; The Eschmann Tracheal Tube Introducer Is Not Gum, Elastic, or a Bougie. Anesthesiology 2004; 101:1240
  3. 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.
  4. Gottlieb M, Sharma V, Field J, Rozum M, Bailitz J. Utilization of a gum elastic bougie to facilitate single lung intubation. Am J Emerg Med. 2016 Dec;34(12):2408-2410. doi: 10.1016/j.ajem.2016.08.057. Epub 2016 Aug 27. PMID: 27614374.
  5. Hodzovic I, Latto IP, Henderson JJ. Bougie trauma--what trauma? Anaesthesia. 2003 Feb;58(2):192-3. doi: 10.1046/j.1365-2044.2003.03005_16.x. PMID: 12562428.