Elastic Bougie

1. Indications
   1. Endotracheal Intubation adjunct
   2. Cormack-Lahane Grade 2A (partial cord view) and Grade 2B (arytenoid view) airways
   3. Airway view obscured by blood or vomit
2. Description
   1. Semi-rigid polyethlene tube or stylet 60 cm long and 5 mm wide (15 French) for adult bougie
   2. Distal end of tube has a 30 degree bend
   3. Endotracheal Tubes that will fit over Elastic Bougie
      1. Adult Bougie: 6.0 mm Endotracheal Tube
      2. Pediatric Bougie: 3.5 mm Endotracheal Tube
3. Images
   1. Bougie Intubation
      1. 
4. Preparation
   1. Direct Laryngoscopy
      1. Bougie may be used without adjusting curvature
   2. Hyperangulated blade (e.g. glidescope) technique
      1. Bougie coiled in pocket will gain a curvature to better navigate anteriorly into the airway
      2. Assistant may need to apply backward pressure on trachea to assist with passage
5. Technique: Laryngoscope method
   1. Insert Laryngoscope in standard fashion
      1. Visualize cords (or at least arytenoids, Cuneiform and corniculate cartilages)
   2. Insert bougie through cords
      1. Bougie may catch at the laryngeal inlet
         1. Rotate the bougie tip by 180 degrees
         2. Advance the bougie and then rotate the bougie back 180 degrees (so tip faces anteriorly)
   3. Pass the Endotracheal Tube over the bougie in seldinger technique
   4. Remove the bougie
6. Technique: Blind method
   1. Insert the bougie with the 30 degree bend (coude tip) pointing anteriorly
   2. Feel the bougie tip slide over the tracheal rings
   3. If Endotracheal Tube is advanced past the 50 cm mark, it is not in the trachea
7. Efficacy
   1. Improves first pass intubation success rate from 85 to 95%
      1. Driver (2017) Ann Emerg Med 70(4): 473–8 [PubMed]
      2. Driver (2018) JAMA 319(21):2179-89 [PubMed]
8. Pearls
   1. Practice using Elastic Bougie when it is not needed (routine, straight forward insertion)
9. References
   1. Bair and Laurin in Wolfson (2016) UpToDate, Endotracheal Tube Introducers, accessed 2/6/2016
   2. Strayer in Herbert (2016) EM:Rap 16(2): 5