A recent RCT from Hennepin1 by Driver et al. evaluated the effect of bougie use on first pass success. This adds to a prior retrospective study by the same group.2 These studies lend support to a practice that many of us have already adapted–bougie first intubation.
Few things on the bougie stuff
- Some bougies are too short & this leads to A LOT of their downsides (RCT used a 70 cm bougie, as opposed to the 60cm bougie that I have)
- Most bougies don't retain their shape, which is a shame b/c the airways where you most need the bend to stay are the ones that are least likely to tolerate multiple removals to reshape. Levitan bougie should solve this
- We cannot conflate the Hennepin article with preloading the bougie
- A discussion is in the episode and 2-person vs. 1 person
Can You Advance an ETT over a bougie without having someone grab the proximal end first?
- Listen to the episode and let me know what you think
How to know the bougie is in when used in a C/L 3 view
- Clicks – I find this unreliable
- Hold-Up – as long as this is done gently, it is fantastic
- Laura Duggan recommends: A trained assistant with gentle thumb on one side, two fingers on the other of trachea at the sternal notch is priceless to confirm placement without the need for the ‘hang up test'
What about the Pre-Load Techniques?
See this poster for one bench eval
I'd also like to see their METTS stylet. Go to VBM Medical to see these.
Snail Trail for Bougie Bending
from3 though I actually put the circle closer to the tip
- Bougie Vids
- EMNerd on the Bougie RCT
- Kovacs on why he doesn't like the D-Grip
- ETT vs. Railroad Bougie vs. Preload Bougie
- Sal on Driver's first study
- This is the highest FPS I have seen using CMAC and Frova on all intubations4
- stand behind the patient
- lift their head
- and push their head towards their feet (causing base of neck flexion)
- until their ear holes (ext auditory meatus) are at or higher than the level of their sternal line (sternal notch to xiphoid process)
- while constraining the face plane to stay parallel to the ceiling
- then padding under head & shoulders until this position is maintained
1st step: head lift or flex lower Cx spine to flatten secondary curve (red curve):
A. obese patient: ~7cm head elevation – poor positioning (at least C&L Gr 3)
B. obese adult: 1x pillow under shoulders & 2x pillows (or equiv) under head = “ramped” or
C. head of bed elevated so ext meatus level with sternal notch
D. adult: normal pillow (~7 cm height)
E. child: small pillow
2nd step: ext upper Cx spine to flatten primary curve (green curve)
Should we still put the head-of-the-bed up?
Prior studies have shown 2 benefits from HOB up:
- For preoxygenation efficacy67
- Glottic Exposure8
Number 2 was the question examined by the Semler paper.5 So the real ? is do we still benefit from #1?
- CC Nerd-The Case of the Anatomic Inaccuracy
- Greenland on the 3-Column and 2-Curve Models
- LitFL on the Same
- George Kovacs on How to Use Towels to obtain pre-look positioning and still allow further neck flexion
Now on to the Podcast…
- EMCrit 290 – Decompensated Hypothyroidism and Myxedema with Dr. Arti Bhan - January 23, 2021
- EMCrit 289 – Ketamine Only Intubation Paper with Brian Driver - January 12, 2021
- EMCrit 288 – Neurogenic Shock & Should we be Using Vasopressors for Hemorrhagic Shock? - December 29, 2020