Best Tips for Bougie Use in Airway Management

August 19, 2024

Written by Aaron Lacy

Spoon Feed
This comprehensive article on bougie use during emergency airway management covers all things bougie, with a lot of technical tips. We cover the highlights.

Bougie = Life
This article goes into a lot of detail regarding bougie use, including general principles and microskills. If you are on the fence about when to use a bougie, you can familiarize yourself with that literature here, here, and here. If you intubate, I recommend reading the whole article (with video examples), but I picked a few things here that are the biggest issues I see repeatedly while teaching bougie use during intubation.

Preparation:

• These authors specifically recommend against “preloading” the bougie. I couldn’t agree more; there is no evidence to support this, and it hampers your ability to utilize the bougie to its full extent. Even if a solo operator, this technique is likely not necessary.

• If you want to pre-curve your bougie be aware it can lose its shape if you do it too soon before intubation, these authors suggest keeping it in a “snail-tail” spiral up until induction.

The Procedure:

• Avoid getting “hung-up”: 1) Rotate the bougie 90° after insertion through the cords. 2) Subsequently, perform a 90° counterclockwise rotation when sliding the endotracheal tube over the bougie to prevent the bevel of the tube from getting caught on the right arytenoid (what I learned as BLT: Bougie Left Turn) can help the procedure go smoothly.

• Hold your glottic view until the tube is in and the bougie is out: Premature withdrawal of the laryngoscope before the ETT visualized passing through the cords and until appropriate depth will cause collapse of soft tissue structures and may inhibit your ability to pass the tube over the bougie. This is a recognized airway error – so hold your hard earned glottic view until the tube is in.

How will this change my practice?
The evidence is either equivocal or supports using the bougie as a primary introducer during intubation. I always go bougie first, but not all fall into this camp. The bougie isn’t a magic wand, however, and takes time to master. As an educator and trainee supervisor, I always advocate for gaining proficiency and microskills with the bougie by using it for every intubation, so when an airway is going bad it’s not your first time picking one up.

Source
Managing Emergency Endotracheal Intubation Utilizing a Bougie. Ann Emerg Med. 2024 2024 Jun 22:S0196-0644(24)00232-4. DOI: 10.1016/j.annemergmed.2024.04.021. PMID: 38912998.