Bougie: Difference between revisions
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==Overview== | ==Overview== | ||
* First described by Macintosh in 1949 ( | [[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 '' | *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% | *Single-center BEAM trial conducted in the ED 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>, however multicenter BOUGIE trial in ICU and ED setting failed to replicate these results.<ref>Driver BE, Semler MW, Self WH, Ginde AA, Trent SA, Gandotra S, Smith LM, Page DB, Vonderhaar DJ, West JR, Joffe AM, Mitchell SH, Doerschug KC, Hughes CG, High K, Landsperger JS, Jackson KE, Howell MP, Robison SW, Gaillard JP, Whitson MR, Barnes CM, Latimer AJ, Koppurapu VS, Alvis BD, Russell DW, Gibbs KW, Wang L, Lindsell CJ, Janz DR, Rice TW, Prekker ME, Casey JD; BOUGIE Investigators and the Pragmatic Critical Care Research Group. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021 Dec 28;326(24):2488-2497. doi: 10.1001/jama.2021.22002. PMID: 34879143; PMCID: PMC8655668.</ref> | ||
* | *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) | *Especially helpful with Cormack-Lehane views II-IV (can be passed blind and placement confirmed with tactile feedback) | ||
* Used in "scalpel-bougie-tube" [[Surgical cricothyrotomy|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 | ||
* | * 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> | ||
** 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 | * 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]] | [[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 | * If resistance is met, retract tube 1-2 cm and rotate 90° CCW, then advance tube | ||
==See Also== | ==See Also== | ||
| Line 70: | Line 65: | ||
**[[Deterioration after intubation]] (DOPE) | **[[Deterioration after intubation]] (DOPE) | ||
== | ==External Links== | ||
*[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] | |||
*[https://prehospitalmed.com/2016/04/14/bougie-intubation-with-the-kiwi-grip/ Kiwi Grip] | |||
*[https://rebelem.com/bougie-use-in-emergency-airway-management-beam/ REBEL EM: BEAM Trial] | |||
*[https://criticalcarenow.com/bougie-bonanza/ CriticalCareNow: Bougie Bonanza] | |||
==References== | |||
[[Category:Procedures]] | [[Category:Procedures]] | ||
[[Category:Critical Care]] | |||
Latest revision as of 15:20, 16 February 2025
Overview
- 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
- Single-center BEAM trial conducted in the ED showed 98% first-pass success using a bougie compared to 87% using stylet for intubation.[3], however multicenter BOUGIE trial in ICU and ED setting failed to replicate these results.[4]
- 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[5]
- 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[6]
- BEAM trial showed no difference in incidence of airway trauma between bougie and stylet groups
Procedure
- 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
- 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
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
External Links
References
- ↑ Macintosh RR: An aid to oral intubation (letter). BMJ 1949; 1:28
- ↑ 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
- ↑ 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.
- ↑ Driver BE, Semler MW, Self WH, Ginde AA, Trent SA, Gandotra S, Smith LM, Page DB, Vonderhaar DJ, West JR, Joffe AM, Mitchell SH, Doerschug KC, Hughes CG, High K, Landsperger JS, Jackson KE, Howell MP, Robison SW, Gaillard JP, Whitson MR, Barnes CM, Latimer AJ, Koppurapu VS, Alvis BD, Russell DW, Gibbs KW, Wang L, Lindsell CJ, Janz DR, Rice TW, Prekker ME, Casey JD; BOUGIE Investigators and the Pragmatic Critical Care Research Group. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA. 2021 Dec 28;326(24):2488-2497. doi: 10.1001/jama.2021.22002. PMID: 34879143; PMCID: PMC8655668.
- ↑ 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.
- ↑ 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.