Bougie First?
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
Technique
- 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
VBM S-Guide
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
Also See
- 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
Update
- This is the highest FPS I have seen using CMAC and Frova on all intubations4
- SR of Bougie First shows clear benefits
- Bougies probably cause less airway trauma than stylets [10.1111/anae.16379]
Positioning
- 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?
For Historical Interest:
Cormack and Lehane in 1984, in their paper on difficult intubation in obstetrics:
“Probably the commonest cause of difficulty for the beginner is not putting the patient’s head in the Magill position. Magill [Br Med J. 1930;2(3645):817-819] showed that the natural tendency to extend the neck is a mistake, since it actually makes intubation more difficult. On the contrary, the neck should be flexed, which ‘may require the insertion of a pillow’, whilst ‘the head is extended on the atlas’. Thus the two main requirements had been clearly stated in 1930…Magill’s original description has never been bettered and can be recommended to all anaesthetists.”[Anaesthesia. 1984;39(11):1105-1111.]
See Also
- 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
Updates:
Now on to the Podcast…
References
Additional New Information
More on EMCrit
EMCrit 299 – Bougie Masterclass with George Kovacs(Opens in a new browser tab)
Additional Resources
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Comment and caution on the Hennepin/Driver paper. This group 1) is highly experienced with bougie aided tracheal intubation (prior to study) and 2) the majority of the intubations in this study were done with bougie and videolaryngoscopy (GLS or C-mac) with most clinicians watching the video screen at some point. Great success with bougie aided intubation, but keep this in mind. I would have hoped JAMA would have paid closer attention to the title. Ramped positioning is not just exposure (as was mentioned)- its major advantage is in the obese. In a world of VL, the finer points of head… Read more »
Will great comments! We discussed extensively in our journal club of the article the used of video as their laryngoscopy method. It is my contention that if they were using DL the discrepancy would have been even higher favoring bougie-first. As to ramped pos. Major advantage in the obese is for FRC/preox. Achieving proper head/neck almost always demands shoulder padding and in essence ramping. But it is my contention that massive obesity should always be preoxed with NIPPV–would love to see whether additional ramping vs. just enough to achieve Ears-to-Sternal-Line is net positive or negative when looking at FPS and… Read more »
Hey Scott great post. Couple of points: 1. There are 2 similar but separate scenarios that explain these Driver bougie results in my view. First the classic use for using a bougie was an epiglottis only view CL 3a views. CL3b are anatomic rarities and most commonly caused the the laryngoscopist deflecting the epiglottis posterior. The incidence of CL3 view in the Driver study was relatively low (although higher than OR studies). The value in using the bougie relates to its use in grade 2 views. These are normally easily managed with a styletted ETT but what happens often is… Read more »
Hey George
amazing comments!
Definition of Kludgy
The updated video you sent makes complete sense, I was going by your former Best Look Laryngoscopy Video which had Ears below Sternal Line and then had you folding in towels to get it up to optimal view, sorry if i misrepresented you.
Can’t wait for the chapter!
Thanks Scott. The podcast is well done. I’m very happy to see my photos here. Proper positioning underpins all airway management: face-mask ventilation, supraglottic airway, laryngoscopy/intubation and infraglottic airway. Interesting how positioning has become so confusing – I’m not sure why this has happened. Although I was taught the 3-axes alignment theory as a junior trainee, I’m no longer a fan. Seems odd to me that the airway is represented as straight lines in diagrams when it and every airway device we use is curved. You don’t need to know what’s under the bonnet of a car to know how… Read more »
fantastic!
Hello Sir, Thank you for the Podcast on Airway tactics. As an ALS pre-hospital provider for a fire department resuscitation and airway is our game. I also had a 6 year stent as a certified flight paramedic, during that time CE class taught us a technique to carry in our difficult airway technique “bag” and something I have been passing to my peers is…. using a pediatric bougie and a Yancauer suction cath as a guide. This technique helped on the anterior and inferior pediatric patient that the bougie had a difficult time making the curve to reach. As you… Read more »
Dear Scott, it was a great airway pearls & tricks. I have 2 question
1) which is recomended to get first pass success position Bed Up Head Elevation (BUHE) v Flextension?
2) occiput-off positioning not recomended?
Cheers!!
Scott Your podcasts are great! I am a paramedic student currently, with a love for all things airway. I am also a visual learner, there is some great pictures here but do you also have some additional videos to reference on the topics discussed? For the positioning do you have any videos showing what you discussed for intubation of patients in the sitting position? Also I work for a service that does not have PEEP valves (frustrating), if I have a patient that I am trying to preoxygenate and am having trouble getting O2 saturation up before intubation are there… Read more »
Nice post, Scott. It plays to all of my biases 😉 Ouir EMA paper is open access – you can link to the full text onliner here: https://onlinelibrary.wiley.com/doi/full/10.1111/1742-6723.12874
great
link is updated
Thanks for another great post Scott. I would add that the third benefit of head up positioning (which you alluded to with the cases you described) is reduction of passive regurgitation and aspiration risk. If the airway is above the stomach, stomach contents are not going to travel uphill (unless the stomach contents are under tension or the pt is actively vomiting). The benefit in FRC of head up positioning is immediately lost on lying them flat. Our O2 reservoir is reduced and thus, so is our safe apnoea time. So why not position our patient in the ideal position… Read more »
Yes, that is exactly what I said in the podcast. If you are using video, the head angulation is easily dealt with. Using DL, not so much–you can still get the job done, but it becomes harder. So you just need to weigh the risks and benefits.
Try using a 1L pressure infuser under the occiput to place them E2SN, have had excellent results thus far. Difficult to carry proper supplies like pillows and extra blankets to the patient’s side in the prehospital environment.
Scott, We have bean using the malleable bougies for about 6 months and they work really well. I personally usually do not bend it but I know a lot of bougie non-believes who actually enjoy it as makes it feel more like a stylet and you can also use it as a stylet by just moving the tubes to the end of the bougie if you need to change things up. We also carry these in bags and often times with the blue bougies once they are bent it is hard to straiten them out again, whereas with these you… Read more »
do u know make and model
Looks like this one
https://www.tri-anim.com/endotracheal-tube-introducers-bougie-type-group-24690-3776.aspx
9 USD per device apparently
Yup, that’s them,
https://www.medline.com/product/Malleable-Introducers-Bougie-by-SunMed/Z05-PF60826
Dr. Weingart, I agree with you that the increase in VL over DL may influence other factors in the ED pre-intubation and peri-intubation positioning of patients. The NEAR investigators, which as you surely know is a nationwide sampling/survey, have shown that there has been a substantial national increase in VL use in the past decade. VL versus DL is a separate and heated topic that I don’t want to get involved with discussing, because the trend towards VL seems unstoppable. I also agree with you that we cannot conflate the positive results of the very successful Hennepin trial (published in… Read more »
agree on all
Great podcast as always. I’ve been using the bougie for almost every intubation since the middle of my intern year. So many advantages over the stylet that it makes me wonder how that ever became the preferred technique. Like you mentioned in your podcast, bending the bougie is often a pointless battle as it resumes it’s shape quickly. Instead, I adjust my angle of approach prior to insertion of the bougie and that has worked for even the most anterior airways. Trying to adjust the angle once you’ve already entered is nearly impossible. Too floppy. I utilize a bougie “double… Read more »
great
Interesting podcast as usual. I work in a tertiary center ED in Quebec City, kids very few and far between. So I was wondering in terms of ear to sternal line, has anyone looked at this for very young children/infants? If you or anybody has any thoughts, I would be glad to hear them.
Thanks, Hugh Scott md
Great post! We use the 60 cm Eschmann bougie at our hospital. As every anesthestist has encountered a lot is that the bougie is a bit to short so you end up feeding it towards the tube millimeter by millimeter, annoying and timeconsuming. What I found is that if you grab the bougie at about 25cm, then the bougies distal end will be possibly to reach after placing the tube. An I mean, if you want to have a “hold up, or clicking” you can advance there and then retract to 25 cm. I have never encountered that I need… Read more »
Hi Scott, Great talk, as always! I did however raise an eyebrow at the suggestion of passing the tube over the bougie without positive control of the proximal end of the bougie before passing the tube… When considering a technique, I have often advocated, and ask myself “how well does this fail”? In experienced hands, this send it home approach may be low risk, and likely would be very slick, but even in experienced hands, misadventure such as lost central line wires still occur. In unrecognized esophageal bougie placement, passing the tube without proximal bougie control raises visions of endoscopically… Read more »
Hi Scott, Great talk, as always! I did however raise an eyebrow at the suggestion of passing the tube over the bougie without positive control of the proximal end of the bougie before passing the tube… When considering a technique, I have often advocated, and ask myself “how well does this fail”? In experienced hands, this send it home approach may be low risk, and likely would be very slick, but even in experienced hands, misadventure such as lost central line wires still occur. In unrecognized esophageal bougie placement, passing the tube without proximal bougie control raises visions of endoscopically… Read more »
Sorry for the double post – my phone and I are not getting along!
hi scott. truly remarkable pod as always.
just re-listened to rich levitan’s series of about ten short lectures he gave in the 2017 EEM conceptos series on day 4. its all very interesting. all these fine points , these details (as described here, and in your prior pods, and in Rich’s conceptos) may make a small (or not so small) difference in first-pass success rates. but “small” is far from trivial when we discuss intubation, especially the trickier ones.
thank you.
tom
Hey Scott,
I have to say that your approach about one provider use of the bougie is spot on. It’s a technique that I’ve been practicing for years. It was taught to me by a well respected physician in my community. It is also the technique that is utilized by the HEMS Critical Care Transport service in my state. I have not heard of one complication arising from this technique, it’s highly effective, fast, and simple.
fantastic!
Late to the conversation but my two cents….. Nick Chrimes’ picture of the problem with sitting the patient up to any degree hits the nail on the head. If you sit the patient up, the line you need to use for ear to sternal line needs to run parallel to the bed/thoracolumbar spine. I think head up is a great idea but the patient needs to be in a suitably ramped position relative to the bed/TL spine. Head up helps oxygenation but does little to the alignment of the larynx relative to the intubator. I’m seeing trainees (and consultants) sit… Read more »
Hi Scott, Thank you for all your work. I was hoping to cite your website, I was wondering if I could use your images in a powerpoint also? Thanks.