However poorly named, the bougie, otherwise known as a gum-elastic bougie or tracheal tube introducer, has become a fundamental part of airway management strategy. When I was a resident, it was fashionable to consider the bougie a backup plan if you were unable to pass the tube with a flexible stylet. It only took my first time needing the bougie to work for me that I realized that it is more than just jamming it in, there are some techniques and subtleties involved.
The Clinical Scenario
In an effort to promote single technique mastery, our residents exclusively use video laryngoscopy with a standard geometry C-MAC blade and a bougie on their first attempt. A common hang-up point for the bougie is just beyond the vocal cords, where the coude tip can get caught on the tracheal ring. The bougies we use are not particularly malleable, so while we are preparing for intubation the bougie is coiled on itself to provide a little curve, and this likely makes the problem more frequent. The normal move at this point is to slightly withdraw and then twist the bougie 720o to rotate the tip enough to free it from the tracheal ring it is caught on.
The torsional flexibily of the device forces an exaggerated twist and multiple rotations to transmit the rotational force down to the tip, while maintaining downward force to maintain position and advance the bougie when the tip becomes clear. Attempting to accomplish this by twisting the bougie with my fingers has generally made for awkward situations and more than once, made me the subject of ridicule and hilarity.
One solution to this is to Draw Circles with the bougie. In this technique, once the bougie tip is just past the cords and no longer advancing, you regrip the bougie as if you’re holding a pencil (the tripod grasp, in case you use an alternative pencil grip), apply a small amount of downward force to make sure the bougie will continue to travel into the trachea, and rotate the bougie as if you were drawing a circle. The bougie turns between your fingers as you do this, and initially it may be easier to execute the turns with your hand further from the tip. This technique has the added advantage of allowing an assistant to turn the bougie while the intubator maintains a view and holds the bougie in place.