Gum Elastic Bougie Assisted Tracheal Intubation
Charles Smith, M.D.
Description of BougieThis 60 cm long tracheal tube introducer has an external diameter of 5 mm to accommodate tracheal tubes > 6 mm internal diameter. The 35 degree angle 2.5 cm from the distal end facilitates insertion through the vocal cords when only the epiglottis (Grade III view) or tip of the arytenoids (Grade II view) can be visualized. A 2nd operator then threads the tube over the bougie. The bougie may need to be rotated 90o for the tube to pass. Every anesthetizing location is equipped with a gum elastic bougie.
Description of Technique
The gum elastic bougie can be used whenever you encounter difficult orotracheal intubation. The technique is as follows: with adequate anesthesia, the operator performs direct laryngscopy and maintains adequate laryngoscopic force to optimize the glottic view. Backwards pressure over the thyroid cartilage can also be employed to improve the view. The operator then introduces the bougie into the patient's mouth and gently advances it through the glottic opening (Grade II view) or anteriorly under the epiglottis (Grade III view) until clicks from the tracheal rings or hold up is felt. With the operator still maintaining laryngoscopic force, a 2nd operator then threads a tracheal tube over the bougie and advances it to a depth of 20-24 cm while maintaining proximal control over the 60 cm long bougie. Occasionally, the bougie and tracheal tube may need to be rotated 90o for the tube to pass. It is relatively easy to insert a bougie through the glottic opening when only the epiglottis (Grade III view) or tip of the arytenoids (Grade II view) can be visualized. Tracheal placement is confirmed using capnography. Auscultation of the lungs is done to insure mid-tracheal position.
References
Nolan JP, Wilson ME: Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia 1993;48:630-3
Smith CE, Michaels E: Tracheal intubation using the gum elastic bougie in an adult patient with epiglottitis: a case report. Am J Anesthesiol 2001; 28:98-100
Smith CE: Rapid sequence intubation in adults; indications and concerns. Clin Pulm Med 2001; 8:147-165
For additional detailed explanation, description and references see Wuscope Fiberoptic Laryngoscope, C. Smith, M.D.