How to Place a Bougie from John McGill

A few years ago, John McGill, of the Hennepin Crew posted an amazing video on bougie placement

Now we have a sequel to take you to next level of bougie use

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Comments

  1. Minh Le Cong says:

    FANTASTIC VIDEO! great cases and technique finesse explained. Combining old and new technologies is very clever and resilient practice. What do they put in the water at Hennepin County ED? I want some!

  2. At first I thought “how to place the bougie? How hard can it be?” …. But these videos are actually quite useful and a good resource to point newbies (and old dogs) towards

    More resources like this please…

  3. After seeing this video I now want a Bougie with both an O2 port or Suction port. I seem to remember a company with a device like this, but I can’t for the life of me find it. A few papers mention “ventilating bougies”, but searching for a product was fruitless.

    • Cook Frova Bougie, hollow design with port at tip for oxygen insufflation. there is a BVM adapter or you can insert a 14G cannula into the proximal end and connect that to extension tubing or 3way tap and jet ventilate or run oxygen using standard tubing

    • Matthieu Gensburger says:

      The Frova is a tracheal tube exchanger. It is designed with a hollow lumen through which you can insuflate oxygen at 2-3l/min during tube exchange. Higher flow or pressure can have dramatic consequences: see http://www.scotcourts.gov.uk/opinions/2010FAI15.html, where an unproperly used Frova catheter caused massive subcutaneous emphysema (scrotum ripped wide open!) and ultimately patient death.

      • thanks Mathieu for highlighting that case. It was a Cook Airway exchange catheter used in the Ewing case , not a Frova. 15L per min oxygen flow was used which is against device instructions. Last week I did jet oxygenate down a Frova inserted into the trachea via a cricthyroidotomy during a live sheep wet lab airway training course. I t works if you be careful of the duration of your jet and freqeuncy..say two jets per minute. its only a rescue measure and the aim is to then railroad an ETT over your bougie . But you are right, normally you should only run two L per min oxygen flow via the Frova or Cook airway exchange catheter.

        • To reinforce Minh’s comments, I would be exceedingly wary of any continuous flow oxygen once the bougie has passed the level of the carina. If you are going to jet ventilate at all (and I would say it is not the best idea) it should be short bursts with plenty of time for exhalatory equilibration.

          • Scott, torally agree! The airway lab I was doing , teaches Dr A Heards strategy and in that they teach both needle oxygenation techniques of using a dedicated Manujet device set at 1bar and a very brief jet of about no more than two seconds. Equally as effective is a simple three way tap and oxygen tubing to flow regulator set at fifteen L per min.
            But like you I do worry about making things too comlplicated kn the rescue airway scenario…what if you cant find a Manujet..or a three way tap?
            The case that Tom and his collegue from NZ alerted us to as well as my own experience is that it can be as simple as holding oxygen tubing onto the cannula hub and then taking it off. Hold the cannula to stabilise with one hand and hold the oxygen tubing to the hub with the other hand, Have one dedicated person doing that and someone else trying to sort out what to do next. Tom and his friend know this works in real life..so do I! I respect DR Heards teachings on his rescue airway strategy though and his approach clearly works..The US army did research a few years ago using two L per min oxygen flow via a tracheal catheter to rescue hypoxic sheep..so a little oxygen goes a long way when delivered in the right place!

  4. Hqmeded strikes again. Fantastic video. In addition to all the troubleshooting it also shows a good variety of the differences in airway anatomy and secretions that you can encounter (aim for the bubbles!). Makes me think back to that video lecture from Dr. Levitan a few weeks back…”A bougie is not a heat seeking missile”

    Also, while we’re on the subject of bougies; what are peoples’ thoughts on using bougie aided endotracheal intubation in a cardiac arrest while chest compressions are still in progess? I haven’t tried it yet but it seems like it could work. If so that could be a great way to eliminate one of the more significant periods of chest compression interruption during an arrest.

    • I’ve not had to use a bougie yet while intubating during continuous chest compressions. During continuous compressions at worst you pass the tube during the rhythm check, at best no interruption is needed.

      Theoretically the bougie could make this easier in that you could pass the bougie during compressions and wait to railroad the tube until the next rhythm check.

    • Mentioned it in some of the comments on Minh’s shows–if you are going to intubate during compressions, the bougie makes things infinitely easier. Smaller cross section to fit through the moving target.

      • Or as Dr McGill demonstrates, use VL and bougie together!
        Love the CMAC in the ED , ICU or OR but too freakin expensive to carry on an aircraft or prehospital. I know a couple of European HEMS units who have done this but you cant spend your whole budget on one device!

  5. Sing Tan says:

    Hi chris

    You may be thinking of the cook airway exchanger. It’s used to swap tubes rather than introduce them, but the concept is the same. They have a port for jet ventilation if needed.

  6. $6 of pure blue plastic awesomeness. Also useful in place of a laser pointer when lecturing, and for smacking the hand of an overeager trauma surgeon who begins unnecessarily prepping the neck while you’ve got the airway management under control. Relax, my trauma friends, I’m joking. And speaking of crics, I won’t get into the whole needle v knife debate, but if you’re using a knife, using a bougie with it I believe is standard of care in 2012.

    Back to bougie as an aid to laryngoscopy… one other tip for easier tube passage over the bougie: once the bougie’s in the trachea, as the airway manager begins to advance the ETT over the bougie, the assistant should “walk their hands down the bougie” continuously as the ETT is advanced, thereby increasingly stabilizing the bougie closer and closer to the patient’s mouth. I’ve found that doing this allows the bougie to be a much more stable platform over which to railroad the tube, which makes tube passage past the larynx quite a bit easier.

  7. Minh Le Cong says:

    found this interesting case report whilst looking for comparative studies of bougie types, single use vs multi use.
    http://www.anesthesia-analgesia.org/content/107/2/603.full

  8. Interesting article, I like these sort of post-event analyses…

    Couple of things truck me – giving lidocaine at induction (I guess this is a North American thing?).

    Also using fingers for thyromental distance – Minh’s fingers and mine might be different – Paul Baker (of ‘difficult airway’ fame in Aus/NZ) has good data to suggest fingers are useless – use centimetres!

    • 3-3-2 using fingers was meant to be done with the patient’s fingers; or at least that is the way it is taught in the Wall’s courses and texts. This allows, this (only mildly) helpful rule to work in patients of all sizes with providers of all finger chubbiness. I must admit, I just look instead of measuring.

      • minh le cong says:

        and that 3:3:2 rule does not consider the physiologically difficult airway… in the unstable patient.. not so helpful.

        • And remember the Levitan and Yentis math: you need to predict 65 difficult airways to find one truly difficult airway (just based on anatomy). And that analysis is for all the difficult airway predictors in total. 3:3:2 is not only just one component but also primarily assesses for space for tongue displacement and an anterior glottis, which are both problems made much better with VL

  9. Brilliant!

    A few points: our disposable bougies are often stored with a slight curve, that is frequently in a different axis than the coude tip, which can lead to big problems during placement. You should check the tip each time.

    I liked his 60 degree curve for difficult airways– looks like a Gliderite stylet! I find that bending the bougie into a circle for a second (about the size of a central line wire) works well, especially in the patient with cspine precautions. (of course, make sure the axis of the circle and the coude tip are aligned).

    Lastly, he didn’t mention Levitan’s best points about the bougie: if you come in from the side, rotating the bougie gives you control in the vertical axis. Also, coming in from the side helps you ensure the tip comes in above the posterior structures.

    And always remember, the bougie is your best friend!

    Seth

  10. Ben Hoffman says:

    The bougie is absolutely an essential bit of kit and it pains me greatly to hear people say “I don’t need it” it is designed to make your life easier and get the tube down so why not use it? I’ve used non-bougie’d tubes with a stylet in them and never again, I absolutely loathe the damn stylet’d tube. Now ironically all my successful tubes have been with non-bougie’d tubes but it was still a pain in the arse compared to sliding them over a bougie.

    I suspect you could use a bougie during CPR and then pass the tube at the rhythm check; no experience with doing that but I think it’d work

    My most creative use for an elastic gum bougie? To put the endotracheal tube in the esophagus; no really I misplaced it ….

    Here’s a tidbit for y’all; the bougie’s inventor was Sir Robert Reynolds Macintosh who “invented” the original bougie out a flexible urinary catheter. He was also a Kiwi, should have just used some number eight wire bro, modified wire-guided intubation if ever I saw one.

  11. minh le cong says:

    check this out. a flying doc colleague did one of these successfully..who needs the VL!
    http://www.baylorhealth.edu/Documents/BUMC%20Proceedings/2008%20Vol%2021/No.%204/21_4_rich.pdf

  12. Don Diakow says:

    Thanks to Doctor McGill and Weingart. Again very practical info for us EMS folks. Our current medical directors and base airmedical directors are encouraging the use of the Bougie for ALL of our out of hospital intubations.
    The use of video by Doctor McGill in this short presentation was spectacular and really drives home the point of how to trouble shoot the Bougie when used.

  13. YYC-MD says:

    Thanks for the skill refresher. Watched this vid when it was posted.

    Tubed bloody mess today with a host of skills from the vid. This post help secure a very difficult airway. Learning in the modern world is awesome.

  14. Juliana Cruxên says:

    Great video

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