Bougie It!

   On a warm Sunday afternoon in July, you and your partner respond to a residence for a reported pediatric drowning. Arriving on scene, you find sheriff's deputies performing CPR on a 3-year-old girl. A hysterical family member tells you the little girl went missing from her grandmother's birthday party about 20 minutes ago, while they were opening presents, and was found in the backyard pool. She was pulled from the pool by her father, who began CPR.

   As your partner works on establishing an intraosseous line and deputies pre-oxygenate the patient, you set up your equipment for endotracheal intubation. As you attempt to pass the ET tube, you lose direct sight of the epiglottis and vocal cords, and a second attempt yields the same result. Your partner, who has placed the IO line, says, "Bougie it!" This time, instead of attempting to place the ET tube, you attempt intubation with the gum elastic bougie, which does not obstruct your view, and you are able to pass it between the vocal cords without difficulty. Your partner then threads the 4.5 mm ET tube onto the end of the bougie and you slide it through the vocal cords to the appropriate depth, at which time your partner removes the bougie. You then assess placement and secure the ET tube according to your guidelines.

Securing the Airway

   Securing a definitive airway in the prehospital environment is often difficult at best. That said, ET intubation continues to be the gold standard for securing a definitive airway for paramedics and, in some states, by EMT-Intermediates, although airway management can often be accomplished using less invasive procedures and still allow adequate ventilation and oxygenation without ET intubation. There are times when the only way to adequately ventilate and oxygenate a patient is with an ET tube. Patients with macerated tongues, vomitus, blood and foreign debris in the airway, to name a few, may significantly benefit from ET intubation and are often the most challenging airways to secure.¹,² For less obvious difficult airways, a quick, simple pre-ET intubation airway evaluation (see Figure 1) can assist in determining whether the patient may present with a difficult airway.³ Both the obvious and not so obvious patients with difficult airways often fall under what the American Society of Anesthesiologists call "cannot intubate and cannot ventilate"⁴ airways, which can lead to patient compromise such as aspiration, trauma to the airway and potentially death. One tool utilized by anesthesiologists for decades to facilitate ET intubation in these types of patients is the gum elastic bougie.

Overview and History

   The gum elastic bougie (GEB), often just referred to as the bougie by EMS clinicians, is an adjunct for difficult ET intubations when the laryngeal inlet cannot be completely visualized.⁵ Research by anesthesiologists, emergency physicians and EMS clinicians has demonstrated significantly improved ET intubation success rates and decreased time required for intubation when using a bougie versus a traditional stylet and ET tube.⁶ This is attributed to the smaller diameter of the bougie versus the diameter of an ET tube. The bougie was first used by Robert Macintosh in 1943 when he encountered difficulty visualizing the vocal cords during ET intubation.⁷ The term bougie originally described any flexible, slender, dilator-type device that was inserted into any body orifice for examination or dilation. The term was also used for wax candles, as bougie is an old French word for fine wax, originating from Bejaia (bougie), a city in northern Algeria.⁸ The current gum elastic bougies are not gummy or elastic, but rigid. The original reusable version is a fiberglass core covered in a beige resin and measuring 60 cm in length, with the distal tip having a 38° bend. Commonly used in the United Kingdom since the 1950s, it gained popularity with anesthesiologists in the United States about 30 years ago, and roughly 10 years ago made its appearance in the EMS community.⁹ It may also be referred to as the gum bougie, tracheal tube introducer or the Eschmann stylet. While it was originally manufactured by Portex, there are now many manufacturers of a bougie-like device, which comes in both reusable and disposable versions.

Types

   There are basically two Portex versions (see Figure 2): the original, reusable version (autoclavable), which was initially used by EMS services for many years, and the disposable version now being adopted by a number of services. The reusable version is 60 cm long; when the disposable version was developed, it was lengthened to 70 cm for better handling. Both versions are 5 mm in diameter (15 French) and are slightly more rigid. The adult version is designed for 6 mm and larger ET tubes and is contraindicated in patients younger than 14 years. Both also come in a 3.3 mm (10 French) pediatric version, which is designed for 4.0 to 5.5 mm ET tubes. Although the pediatric version is actually classified as an ET exchange guide and does not have the 38° distal bend, it was designed to be used as both. The average cost for the disposable version is $6 to $7.50 each, depending on quantity; the reusable version costs around $20 each. The steps for using both the adult and pediatric versions are the same, except that users need to create a bend to the distal end of the pediatric version.

Steps for Use

   The bougie may be used in the patient with a known difficult airway from past history, exam, an unsuccessful ET intubation attempt or an anticipated difficult ET intubation. Once it is determined that a bougie is needed, remove it from the package and lubricate the distal end with K-Y jelly. With the pediatric bougie, create a bend to the distal end, wearing sterile gloves to do so, and then lubricate it. Perform laryngoscopy in the normal manner. If the vocal cords and/or inlet to them are not completely visible, insert the distal end of the bougie with the bend up into the oropharnyx and attempt to place it into the larynx the same as an ET tube. Since the bougie is rigid, it should be carefully and slowly advanced so as to not inadvertently lacerate or perforate the trachea, which could be potentially catastrophic.¹⁰,¹¹ Correct placement may be confirmed with tracheal clicks as the bougie catches the tracheal rings, and/or a slight hold-up may be felt in 65%-90% of cases,¹² both of which are indicative of tracheal placement. Whereas in adult patients no clicks and/or no hold -up indicates esophageal placement, in younger patients this may not be true, since tracheal clicks and/or hold-ups may be more difficult to appreciate because their tracheal rings are not fully developed and rigid.

   Leave the laryngoscope in place as your partner threads the proper size ET tube over the bougie. Once the ET tube clears the end of the bougie, advance it through the cords while your partner stabilizes the top of the bougie. If the ET tube sticks or hangs up at the inlet to the larynx, rotating the ET tube 90 degrees counterclockwise may allow it to advance. Hold the ET tube securely in place while your partner slowly extracts the bougie, then remove the laryngoscope. Inflate the cuff, and confirm and secure the ET tube following your guidelines.

   A second method of using the bougie is to "load" the ET tube over the bougie prior to the intubation attempt instead of using a stylet, although the weight of the ET tube may interfere with your ability to manipulate the bougie. Working with both methods during training allows you to decide which method you prefer.

   Lastly, the bougie may also be inserted blindly into a patient's airway.¹³ An example would be a trapped patient in a vehicle with prolonged extrication, where bag-valve mask ventilations have proven inadequate and you have exhausted all other options. Slide the bougie into the patient's airway. If tracheal clicks and/or a distinct hang-up are felt, an ET tube can be "railroaded" over the bougie without the aid of a laryngoscope. Remove the bougie and follow local guidelines for assessment and securing the ET tube.

Training Program

   Initial and ongoing training with the bougie may be done as part of an airway course, review or stand-alone program. Initial training on the bougie can be accomplished within an hour. A short 15-minute lecture reviewing airway anatomy, the history of the bougie and use of the bougie in difficult ET intubations can be followed by a short video of its use and/or a demonstration on an airway management training simulator. The tracheal clicks and hang-up of correct placement can be appreciated by using corrugated respiratory tubing and sliding the bougie along the inside wall. Following that, allow time for hands-on practice using the adult and/or pediatric bougie, and, if the service desires, perform a skills check-off or verification. Most services choose to review the bougie once a year, while services that are adopting new and/or emerging airway management devices may choose to review bougie use more often.

Conclusion

   The bougie is a relatively inexpensive airway management adjunct that can assist the paramedic and/or advanced EMT in securing a definitive airway in a compromised patient with a "cannot intubate and cannot ventilate"1 airway, potentially averting long-term compromise and/or death to the patient. All services utilizing ET intubation should carry and train on use of the bougie. Imagine the drowning case from the beginning of the article in the year 2014. A first-attempt ET intubation is conducted utilizing a videoscope and bougie, the ET tube is passed on the first attempt, the 3-year-old is transported and lives to attend her grandmother's birthday party the following year.

   A special thanks to Century College Paramedic students Greg Teece, Shane Westphal, and Nicole Bryant for assistance with the photos for the article.

Figure 1: Predicting the Difficult ET Intubation

This pre-ET intubation airway evaluation can assist in determining whether the patient may present with a difficult airway.

History and Examination

• Pregnant patients (third trimester, increased body mass)
• Facial and/or maxillary trauma
• Small mandibles
• Protrusion of the mandible
• Overbite
• Short, fat necks (bull neck)
• Morbidly obese
• Broken teeth
• Abnormally shaped face
• Oral infections
• Oral and/or upper airway tumors
• Rheumatoid disease and/or degenerative diseases of the spine
• Inability to open the mouth from obesity, deformity, injury
• Suspected spinal cord injury (requiring manual c-spine stabilization)

Screening Tests

• Thyromental distance
    Measured from the upper edge of the thyroid cartilage to the chin with the head extended. The shorter the distance, the less room within the oral pharnyx. Less than three fingers suggests a difficult intubation.
• Mouth opening
    Should be a minimum of two fingers, three is preferred.
• Mallampati test
    The patient faces the clinician and opens their mouth, extending their tongue. Based on the view, difficulty in ET intubation can be estimated. Granted this is seldom the case in emergent intubations, but may be attainable in the pulmonary edema patient in whom medications may be used to facilitate intubation. In an unconscious patient, a tongue blade or laryngoscope blade can be used to get an idea of the potential difficulty prior to the attempt.
  • Grade 1: No problems
  • Grade 2: No problems
  • Grade 3: Moderate difficulty
  • Grade 4: Difficult
• Cormack and Lehane Classification
    Is based off the following views and as the view decreases, the difficulty in the intubation increases.
  • Class I: Vocal cords visible
  • Class II: Vocal cords partially visible
  • Class III: Only epiglottis visible
  • Class IV: Epiglottis not visible

   

  References
  
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  2. Kaye K, Frascone R, Held T. Prehospital rapid sequence intubation: A pilot training program. Prehosp Emerg Care 7(2):235-240, 2003.
  3. Wilson IH, Kopf A. Prediction and management of difficult tracheal intubation. Update in Anaesthesia: Practical Procedures 9:1-4, 1998.
  4. Miller CG. Management of the difficult intubation in closed malpractice claims. ASA newsletter, v. 64, 2000.
  5. Viswanathan S, Campbell C, Wood D, et al. The Eschmann tracheal tube introducer (gum elastic bougie). Anesthesiology Review 19:29-34, 1992.
  6. Gataure PS, Vaughan RS, Latto IP. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Anesthesia 51:935-938, 1996.
  7. Macintosh RR. An aid to oral intubation. Br Med J 1:28, 1949.
  8. American Heritage Dictionary, 2009.
  9. McCarroll S, Lamont B, Buckland M, Yates A. The gum-elastic bougie: Old but still useful. Anesthesiology 68:643-644, 1988.
  10. Arndt G, Cambray A, Tomasson J. Intubation bougie dissection of tracheal mucosa and intratracheal airway obstruction. Anesthesia and Analgesia 10(2):603-604, 2008.
  11. Prubuha A, Pradhan P, Sanaka R, Bilolikar A. Bougie trauma--It is still possible. Anaesthesia 58:811-813, 2003.
  12. Airway-Cam (2010). Technique for oral intubation. Direct laryngoscopy. Bougie (tracheal introducer).
  13. Nolan JP, Wilson ME. Orotracheal intubation in patients with cervical spine injuries: An indication for the gum elastic bougie. Anaesthesia 48: 630-633, 1993.

     Scott Tomek, MA, EMT-P, has been a paramedic for 25 years, 23 with Lakeview Hospital EMS in Stillwater, MN. He is a faculty member with the Century College paramedic program, and a curriculum development specialist.