bougie in the blind intubation

[Painter1]

had a nightmare intubation the other day. obese patient with no neck.

have any of u guys sedated only with etomidate without paralytics to "take a look" in such a patient?

anyway, the patient's o2 sats dropped like a rock after succs. couldn't bag, couldn't intubate. i ended up using an LMA after everyone from the nurses to the resp tech and myself had soiled our undergarments. thankfully, LMA worked.

so i've used the bougie in cases where i saw cords or partially saw cords and i was unable to pass the et tube. however, i've never used it in a blind intubation.

what r u guys experience with blind intubations using the bougie? anesthesiologist came down and swapped out the lma. he used the bougie as he was able to see the very tip of the epiglottis and ran it underneath.

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[Paseo Del Norte]

Sounds like you did a great job. You recognised a failed airway and rescued it with a supraglottic. My experiences with using the bougie in the Prehospital environment have been very positive.

However, in your situation, your patient was desaturating and you could not effectively mask ventilate. At this point, you simply don't really have the time to mess around with a bougie. I think it's a great option in a difficult or predicted difficult intubation where you have a patient who is saturating reasonably well and can be mask ventilated. It's an option for "blind" intubation; however, as stated, it sounds like it was not a good option in your specific scenario.

My thoughts for what they are worth.

 

[Arcan57]

had a nightmare intubation the other day. obese patient with no neck.

have any of u guys sedated only with etomidate without paralytics to "take a look" in such a patient?

anyway, the patient's o2 sats dropped like a rock after succs. couldn't bag, couldn't intubate. i ended up using an LMA after everyone from the nurses to the resp tech and myself had soiled our undergarments. thankfully, LMA worked.

so i've used the bougie in cases where i saw cords or partially saw cords and i was unable to pass the et tube. however, i've never used it in a blind intubation.

what r u guys experience with blind intubations using the bougie? anesthesiologist came down and swapped out the lma. he used the bougie as he was able to see the very tip of the epiglottis and ran it underneath.

Question 1: Yes, I've used etomidate without paralytics on someone I thought was going to be a difficult airway. However, you're then sedating someone with a (usually) unknown NPO status and all the aspiration risk that entails. Sometimes that's the lesser of two evils, but there is a reason RSI is the standard.

Question 2: Define blind intubation. Where you see the epiglottis but not cords? That was the situation for which the bougie was invented. When you can't see epiglottis? If that's the case I guess it would depend on what was the reason for non-visualization. If the anatomy is so distorted that you can't see epiglottis, passing a bougie blindly is not going to have a high rate of success. I'd be thinking about a Glidescope (if you stand on the supports at the head of the stretcher, you can bend down and intubate someone who's sitting bolt upright), supraglottic airway, or preparing for what will certainly be a flail of a crich.

 

[kungfufishing]

Do you have an intubating LMA? I mean, I assume not since you used a regular LMA, but if you could acquire one this is a scenario for it. Have taken a look after the etomidate several times, have used ketamine for this as well in a patient who defied the laws of physics/airway prediction and ended up having a trachea the janitor could have tubed (after alllll that....).

 

[WilcoWorld]

Do you have an intubating LMA? I mean, I assume not since you used a regular LMA, but if you could acquire one this is a scenario for it. Have taken a look after the etomidate several times, have used ketamine for this as well in a patient who defied the laws of physics/airway prediction and ended up having a trachea the janitor could have tubed (after alllll that....).

Those are the best - when you, Respiratory Therapy, Nursing, etc are all on pins & needles over this nightmare airway, you take a look and...swoosh

 

[southerndoc]

I have only used a bougie once and that was during residency. Luckily I have a GlideScope at my disposal and anesthesia in house as backup if I can't get it with the GlideScope.

 

[ManchesterDoc]

well done in a difficult situation!

despite the numerous new airway toys out there, the bougie has always been a great friend. No need to set anything up or wait for anything to power up. I had a similar case to you though the guy had already arrested. four failed intubations by two different operators. It is certainly is a help if you can at least see the tip of the epiglottis, but regardless if you must pass it blindly, the way of confirming you're in the right place is to brush the tip along the tracheal rings.

again, well done!

 

[zeitgeber]

I've used the bougie for blind intubation with great results... It doesnt always work, but if you can't see the airway it is a great tool. I've also used etomidate without a paralytic, and while it's useful to take a look i often find that for difficult intubations you either don't get them fully relaxed or their cords are adducted and i'm forced to use a paralytic. Sounds like you did fine with the LMA as a rescue.

 

[Painter1]

thanks to everyone for your input.

i'm glad the LMA worked. never had to use it. in training we used the Airtraq which is a disposable optimal laryngoscope device.

at one point I was able to see the very tip of the epiglottis. now it's more clear that this is the occasion where the bougie could be most helpful.

i imagine u just closely follow the underside of the epiglottis and ideally feel for the tracheal rings?

 

[Paseo Del Norte]

thanks to everyone for your input.

i'm glad the LMA worked. never had to use it. in training we used the Airtraq which is a disposable optimal laryngoscope device.

at one point I was able to see the very tip of the epiglottis. now it's more clear that this is the occasion where the bougie could be most helpful.

i imagine u just closely follow the underside of the epiglottis and ideally feel for the tracheal rings?

Yes, tracheal clicking as it's called is a very positive sign. Also remember that the endotracheal tube can get caught on the cartilaginous glottic structures. If this occurs, you can try twisting the distal end of the tube to dislodge it.

Was helping a doc exchange a tube last week and he simply could not advance the new tube. Patient desaturated and we ended up pulling out and bagging the patient. Luckily, the doc had just finished a bedside bronch and we were able to reintubate using the scope. Best laid schemes...

 

[Mighty Mouse]

also....another indicator that the boogie is where you want it.....yes, you'll get the tracheal ring click (in theory). if the boogie abruptly stops, then odds are you're hitting the carina.

if you have no clicks and the boogie seems to go down forever, then you're in the goose.

 

[Altruist]

Was helping a doc exchange a tube last week and he simply could not advance the new tube.

From my prehospital days, one of the bloodiest messes (in the American, liquid sense) of an intubation I was ever witness to involved a coworker Conan-ing the tube over a Bougie. There's a reason you're supposed to keep the laryngoscope in (which my coworker didn't do) and rotate the tube 90 degrees as it goes past the cords. Probably a good idea to lube it up as well if you're really thinking ahead.

It's also worth pointing out that to use it correctly (or at least as the manufacturer recommends), you do need someone else to put the tube on for you and then hold the bougie while you advance the tube... what I'm getting at is that you need to educate your staff as well, if you're going to start using it.

I do think the Bougie (or its generic equivalent, the "flex-guide ETT introducer," and there's at least one other model) is especially good for EMS difficult airway kits due to its low cost and simplicity... that said, I imagine we'll all move to the airtraq or something similar as prices come down.

 

[lushmd]

A few thoughts from an anesthesiology resident's perspective (not criticisms per se, but rather constructive advice that can be applied to future situations):

(1) Was induction of anesthesia necessary or would an awake approach have been feasible in a patient with risk factors for difficult ventilation and intubation (obese, no neck, etc...)?

(2) After deciding to induce general anesthesia, was there consideration for using an agent (such as ketamine) that wouldn't ablate spontaneous respiration?

(3) Use of an induction agent without a paralytic (your original question) is a source of some contention in Anesthesiology (there was a recent thread covering this in the Anesthesiology forum). The argument for not paralyzing is of course to maintain the possibility of awakening the pt in the event of a cannot ventilate/cannot intubate scenario. I (and others) would argue that, in a true cannot intubate/cannot ventilate situation, spontaneous ventilation is unlikely to return in time to prevent significant hypoxemia following induction of general anesthesia with an agent such as etomidate (i.e. the more critical decision is whether or not induce and with what agent vs whether or not to paralyze). Furthermore, administration of paralytic in this situation would only increase the likelihood of succesful intubation/ventilation.

(4) Re appropriate use of the bougie (Eschmann stylet in case you try a lit search): its meant to be used with Cormack-Lehane grade II-III views with laryngoscopy (i.e. view of the some aspect of the glottic aperture or of the epiglottis, respectively) but not purely blindly (the "clicking" of the bougie tip along tracheal rings is quite specific but not very sensitive). Although its a great tool, inappropriate use of the bougie can result in significant trauma. Also, in this situation, purely blind passage of the bougie and subsequent ETT insertion may well just waste time that would be better spent at least obtaining adequate ventilation through an LMA or intubating LMA (as you appropriately did in this case) or even a surgical airway depending on the circumstances.

 

[Paseo Del Norte]

From my prehospital days, one of the bloodiest messes (in the American, liquid sense) of an intubation I was ever witness to involved a coworker Conan-ing the tube over a Bougie. There's a reason you're supposed to keep the laryngoscope in (which my coworker didn't do) and rotate the tube 90 degrees as it goes past the cords. Probably a good idea to lube it up as well if you're really thinking ahead.

It's also worth pointing out that to use it correctly (or at least as the manufacturer recommends), you do need someone else to put the tube on for you and then hold the bougie while you advance the tube... what I'm getting at is that you need to educate your staff as well, if you're going to start using it.

I do think the Bougie (or its generic equivalent, the "flex-guide ETT introducer," and there's at least one other model) is especially good for EMS difficult airway kits due to its low cost and simplicity... that said, I imagine we'll all move to the airtraq or something similar as prices come down.

We were actually doing it "by the book" so to speak. We lubricated the bougie and new ETT prior to performing the exchange. Heck, we even hit the two minute oxygenation for "suction" button on the ventilator. The doc attempted to rotate and the ETT simply would not pass. As soon as the patient dipped into the upper 80's we were out and bagging.

Even more interesting was the fact that the doc could not visualise worth a crap using direct laryngoscopy in spite of positioning and ELM. The patient was thin and had no external indications of a difficult airway; however, looks can be deceiving...

My experience with the Airtraq has been mixed in my anecdotal opinion. We currently use it as an alternative at one of my transport jobs. We currently have mixed results after a little over two years of using this device. However, I have good things to say about the Glidescope and think the Ranger definitely has a role in the pre-hospital environment. The Glidescope seems to be proliferating within the hospital. So, I agree that we will likely see more of this type of technology.

 

[Coastie]

had a nightmare intubation the other day. obese patient with no neck.

have any of u guys sedated only with etomidate without paralytics to "take a look" in such a patient?

anyway, the patient's o2 sats dropped like a rock after succs. couldn't bag, couldn't intubate. i ended up using an LMA after everyone from the nurses to the resp tech and myself had soiled our undergarments. thankfully, LMA worked.

so i've used the bougie in cases where i saw cords or partially saw cords and i was unable to pass the et tube. however, i've never used it in a blind intubation.

what r u guys experience with blind intubations using the bougie? anesthesiologist came down and swapped out the lma. he used the bougie as he was able to see the very tip of the epiglottis and ran it underneath.

Sedated? You mean induced general anesthesia with etomidate?

If full stomach, then do RSI...or awake FOB if airway looks difficult.

I've used a bougie "blindly"...but it's because I didn't have a video laryngoscope in the situation..

 

[Venko]

I too have used the bougie blindly and if you meet resistance at the marker, you know you're in the airway. It works great and only takes a few seconds to try.

I have used etomidate without paralytic, but I find that not uncommonly, patients will vomit given that they usually stopped at McDonalds on the way to the ER, and then we bag them...I have decided to not use that again my practice without paralytic in conjunction.

Do you have fiberoptics? ENT? in hours Anesthesia? These are things I would have tried to assemble for this patient too. This patient had all the signs of a "difficult" EM airway from the get go...but sometimes there is no time to do these things....just a thought.

 

[crewmaster1]

Had a tough tube on an ARDS patient the other day and used the high flow nasal cannula trick I read about in one of the EM throwaway journals last month (EM news???). On a NRB mask sats 93%, added a nasal cannula at 15lpm to the NRB and sats up to 98%! It was awesome. Then had a super tough intubation, but left in the NC at 15lpm and had a much longer apnea time without hypoxia than expected. Finally got the airway with a blue bougie! I was still able to bag the pt up with NC in place during tube attempts. Have seen someone put in a bougie and then bag the patient up from hypoxia before inserting the ETT. It's a bit tricky and cumbersome, but can be done.

The bougies are also awesome for crics. Called a "bougie aided cric." Also read about in a throwaway mag, one was done in our ER and it was awesome. One major problem with crics is losing the opening after making it, but if you easily insert a bougie you get tactile feedback you're in the right place and you can still slide a 6.5 ETT over a bougie into the trachea vir cric!

 

[EMRAGE]

First I would drop two nasopharngeal airways and bag. This seldom fails.

I wouldn't hesitate to perform a blind bougie. if you've come to that point, what do you have to loose. I would also consider a retrograde intubation or intraoral palpatory intubation (i.e. use your fingers to help guide the tube anteriorly).

I too hate to paralyze a difficult airway. Always have the Succs drawn-up and ready. Bruxism can ruin your day. If you've slapped in the nasal trumpets, you have much less to worry about in that case.

King airways are the best followed by LMAs in a pinch.

RAGE

 

[southerndoc]

I had the worst airway in my career recently. An obese woman, no neck, very anterior, whose mouth wouldn't open that wide. Couldn't visualize cords even with a GlideScope. Had anesthesiology come down and on the fourth attempt, they could see the bottom of the cords and managed to use a bougie to get a tube in. Yes, a bougie with a GlideScope.

They had called for a fiberoptic but they got it before the OR staff could bring it to the ED.

 

[leorl]

Had a similar case the other day in actually a lady we didn't expect to have a difficult airway. Fortunately this lady never desaturated, but 3 attendings tried, then I tried with the glidescope and found the trachea but my ETT wouldn't pass for who knows what reason, then we were running around trying to find the bougie and / or a fiberoptic but of course they weren't in the airway cart. So one of the guys pulls out a lighted stylet, which i'd never seen before. Lady was intubated in 3 seconds with that baby.

 

[Arch Guillotti]

Pardon my intrusion, but why the heck did you guys keep on DL'ing when it obviously wasn't working (4 providers each with at least one try?). Simply switching providers isn't likely to do much good unless someone is just not very good at intubating.

Had a similar case the other day in actually a lady we didn't expect to have a difficult airway. Fortunately this lady never desaturated, but 3 attendings tried, then I tried with the glidescope and found the trachea but my ETT wouldn't pass for who knows what reason, then we were running around trying to find the bougie and / or a fiberoptic but of course they weren't in the airway cart. So one of the guys pulls out a lighted stylet, which i'd never seen before. Lady was intubated in 3 seconds with that baby.

 

[quagmire223]

Yeah, partly to buy more time and partly because two of those attendings are new attendings. On DL, landmarks could be seen but it was just difficulty with passing the tube (not quite sure why since the ETT entered the field of vision, but wouldn't pass completely, no matter what angle was tried). anesthesia was paged, but intubation was achieved before anesthesia got there.

 

[Hamhock]

i have always learned that the bougie is CONTRAindicated in FAILED airways...intended for difficult airways, but not failed airways - these require rescue devices, which the bougie is not

perhaps this is just semantics, but many of the posts above (ie multiple looks, can't see anything, sat's dropping, and can't ventilate now is a failed airway, NOT a difficulty airway) seem to be asking about bougie in a failed airway, which is something i admittedly haven't tried - but never will

HH

 

[Arch Guillotti]

i have always learned that the bougie is CONTRAindicated in FAILED airways...intended for difficult airways, but not failed airways - these require rescue devices, which the bougie is not

perhaps this is just semantics, but many of the posts above (ie multiple looks, can't see anything, sat's dropping, and can't ventilate now is a failed airway, NOT a difficulty airway) seem to be asking about bougie in a failed airway, which is something i admittedly haven't tried - but never will

HH

Depends on your definition of "failed". I have seen normal airways turn into failed airways because of multiple attempts that make things worse, patients that need crics and emergent jet ventilation, failure to DL but tube placed by alternate means plenty of times, etc.

I think the bougie is not too great for a blind tube, I think is is the best for poor grade 2 or view of the epiglottis only.

 

[Arch Guillotti]

Had a similar case the other day in actually a lady we didn't expect to have a difficult airway. Fortunately this lady never desaturated, but 3 attendings tried, then I tried with the glidescope and found the trachea but my ETT wouldn't pass for who knows what reason, then we were running around trying to find the bougie and / or a fiberoptic but of course they weren't in the airway cart. So one of the guys pulls out a lighted stylet, which i'd never seen before. Lady was intubated in 3 seconds with that baby.

It is hard to take a step back from situations like this especially if the situation is urgent/emergent but perseverating with DL can sometimes get you in trouble. Alternative airway devices like the lightwand can really save your butt and make you look slick all at the same time.

 

[EMRAGE]

In my opinion, there are few contraindication to bougie attempt. If you can identify any anatomy in the retropharynx, I would try the bougie. If you feel the clicking of trach rings, you are very, very likely to be in the airway. Feed the tube and see where it goes.

Everything to gain and nothing to lose IMO.

RAGE

 

[corpsmanUP]

This has been a very informative thread! I am a huge proponent of the bougie, and on more than one occasion it has saved my rear. I use it when the tube just won't make the bend for some reason, or when the Glidescope alone won't let the tube pass. I've found that almost any airway is tamed with a Glidescope and bougie combo. But those are usually unanticipated difficult airways and the tension during those bad boys is high. I often use the Glidescope to let the PA's practice with it or when I am worried it might be a tough airway.

That said, the bougie really is an incredible device, but it has a learning curve. And each brand is a little different feel. I just had a paper come out last month about the bougie in difficult airways and we used the Sunmed brand which at current it my favorite. It's a little more rigid than the others.

Just today I was playing around in the office with the Airtraq and the bougie and wondering how well the two could work together. It's a little tough.

 

[pgg]

i have always learned that the bougie is CONTRAindicated in FAILED airways...intended for difficult airways, but not failed airways - these require rescue devices, which the bougie is not

I don't think there's any real contraindication to using a bougie.

As a blind tool, the bump-bump-bump of its tip going over the tracheal rings is often enough.