"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


  • 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


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


  • 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


  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.