The bougie, often referred to as the gum-elastic bougie, is neither gum-elastic nor a bougie. It is probably best to call it an endotracheal tube introducer but it is widely known as the bougie. Nonetheless it is a device essential to emergency airway management.

During my initial paramedic training, I received very little education on the bougie. My love for this device has only come through my own realizations as I have expanded my airway knowledge through FOAMed and advanced airway courses. Also, my good friend Jorge Cabrera (@In10sivist), is a bougie fanatic and has taught me a great deal about the nuances of this tool. The traditional view of the bougie is that it is a “rescue” device and is only needed in challenging airway situations. In fact, many providers view the bougie as a form of “cheating” and imply that if you use it you have, in some way, failed. This mindset is not only ridiculous, it is dangerous, and discourages the application of a safe device that can really save you and your patient.So why is a bougie so useful? The objective answer is that it allows you to intubate patients with a more limited glottic view. As a general rule, it is best not to try to pass a styletted tube with a view that is worse than grade 2A. This is because anything worse does not allow you to visualize the tube entering the cords. Additionally, an ET tube is large and often obscures your view of the cords while trying to maneuver it to them.

A grade 2A view is the minimum safe view that should be used for a styletted tube. But with a bougie, you can now safely and reliably deliver a tube with a grade 3A view. The coudé tip can be carefully passed beneath the epiglottis and up into the larynx. This is obviously not optimal, as it is always best to try to visualize the cords. But if you can only see epiglottis after performing epiglottoscopy, elevating the head, doing external laryngeal manipulation, and using your mac blade as a miller, you do not have to abandon your attempt.

You may be asking, “but couldn’t you just have a bougie ready and only use it if you need it?” Of course the answer is yes, but why not use the device most likely to be successful on every intubation? The modern airway approach is designed to achieve first-pass success. If you plan to use an ET tube with a stylette it is probable that you will try this approach first, regardless of whether your view is adequate. You are psychologically more likely to attempt your initial plan even if you should not. This means that you may end up wasting time jabbing a tube around the pharynx, causing trauma, and prolonging your attempt.
It is also markedly easier to pass a bougie through the cords and down the trachea than it is to pass a tube. Even with a perfect view of the larynx you can still run into issues advancing the tube. The primary reason for this is impacting the cricoid ring with the tube tip. This can often be overcome by rotating the tube 90° clockwise, but why risk it? Passing a bougie gives you a guide into the trachea. It is the Seldinger technique of

airway management. Once it is placed you have a reliable route to deliver your ET tube. “But what if the tube gets caught on the cords?” This is a relatively common, but easily overcome issue. If the tube is passed with the bevel left, as most tubes are designed to be by default, the tip may get caught on the right vocal fold. This is resolved by simply rotating the tube 90° counter-clockwise. This puts the bevel down and allows the tip to pass between the cords. My preference is to rotate the tube as I advance it so this is never an issue.

But there are other advantages to the bougie. The best part for me is the instant placement confirmation. You have immediate feedback about whether the bougie is in the trachea or the esophagus in the form of tracheal clicks. As the coudé tip advances down the trachea, it rubs against the tracheal rings. This is palpable as clicks felt when gripping the bougie. Many will say that these cannot always be felt.

ANECDOTE AHEAD: In forty two cadavers and many live intubations I have been able to feel tracheal clicks in every person. This is not to say there aren’t patients that clicks cannot be felt in. The key is ensuring the coudé tip remains pointing upward. If the tip rotates to the side or downward, it will not be against tracheal rings and the clicks will not be felt. You also must advance the bougie slowly (for many reasons) and consciously feel for clicks, as sometimes they are subtle. Additionally, you can ask an assistant to place their hand on the trachea and they will also be able to feel the clicks.
The other way that placement can be confirmed is by achieving hold-up in one of the proximal bronchi. If the bougie has been placed properly, it will only advance a short distance before impacting the carina and then lodging in the bronchi. If it is placed in the esophagus, it will not stop advancing. This method is somewhat controversial due to the risk of tracheobronchial trauma. This risk can be mitigated by advancing the bougie very slowly when attempting to achieve hold-up. However, my personal approach is not to achieve hold-up if I have felt tracheal clicks. I will advance far enough that the bougie will not dislodge from the trachea and stop. This avoids the risk of airway trauma. But, if clicks are not felt and you believe the bougie is in the right place, advancing slowly and achieving hold-up is a reliable way to confirm placement.

The last reason I use a bougie on every intubation is familiarity. The more you perform a skill the better you will be at it, especially in live patients. Using the bougie on “easy” intubations increases familiarity and experience with the device. This way, when you really need it, you will be comfortable handling it and know what to expect.
I view the bougie as the stylette is viewed now. When stylettes first became mainstream, there was stigma against them and there was a view that using them was “cheating”. Today, in most modern countries, the stylette has become the standard of care and intubating without it is seen as inferior because of its ability to make tube delivery significantly easier.

Video: Sam Ghali, @EM_Resus

Bougie Tips
A common error is removing the laryngoscope from the mouth once the bougie is placed. Your view of the larynx, however excellent or restricted it is, should be maintained until the tube is placed. There are two reasons for this. Number one is to ensure the bougie does not dislodge and to try to visualize the tube entering the trachea to confirm it goes in the right place. The other is that removing the laryngoscope causes the upper airway to collapse on the bougie making it more difficult to advance the tube. This can also cause bougie dislodgement if it is not advanced far enough into the trachea.

The bougie is generally not recommended when using indirect video laryngoscopes (i.e standard Glidescope, CMAC D-Blade). These are devices that can only be used for video laryngoscopy and are not shaped to perform direct laryngoscopy. The reason for this is that they do not displace airway tissue and create a steep angle to the cords. The best way to deliver tubes when using these devices is a hyperangulated stylette with a 60-70° bend that matches the bend of the blade.

There are many techniques out there involving preloading the ET tube and different grips. I prefer to use the bougie “naked” without preloading the tube. I feel that it gives me more control and better ability to feel trachea clicks. The tube is then advanced by another provider over the bougie or I hold the bougie against the laryngoscope with my left hand and load the tube myself with my right hand. The tube is then advanced and passed between the cords. This is not evidence based and many techniques may be equally effective. Practice all of them and find one that works best for you. The Shaka grip gives you the ability to elevate the tip of the bougie with your pinky which may help maneuver below the epiglottis. It also provides a direct indication of which way the coudé tip is pointing to ensure it stays upright. There are many different ways to preload a tube including the D-grip or Kiwi grip.

The bougie can be especially useful with an Omega shaped epiglottis. It can be difficult to pass a tube but the epiglottis acts as a conduit for the bougie.
(Videos: Sam Ghali, @EM_Resus)

Quick points because of things I’ve seen attempted:
-Do not use straight (non-coudé) tip bougies. They will not generate tracheal clicks and may be more likely to cause trauma as they will advance further into the tracheobronchial tree.
-Do not attempt to blindly place a bougie. It is not a heat-seeking missile.
-The smallest tube that will fit over an adult bougie is 6.0 mm, pediatric 3.5 mm.

Feel free to contact me with any comments, questions, or concerns
amerelman@gmail.com
@amerelman

References

https://ruraldoctors.net/anaesthesia/airway/

Novel Tips for Airway Management

https://lifeinthefastlane.com/ccc/bougie/

Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496.

Driver, B., et al. (2017). The Bougie and First-Pass Success in the Emergency Department. Annals of Emergency Medicine. doi:http://dx.doi.org/10.1016/j.annemergmed.2017.04.033

Kidd, J. (1988). Successful difficult intubation. Use of the gum elastic bougie. Anaesthesia, 43(6).
doi:10.1111/j.1365-2044.1988.tb06625.x

Gataure, P., et al. (1996). Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Anaesthesia, 51(10).
doi:10.1111/j.1365-2044.1996.tb14961.x

Phelan, M. (2004). Use of the endotracheal bougie introducer for difficult intubations. The American Journal of Emergency Medicine, 22(6). doi:https://doi.org/10.1016/j.ajem.2004.07.017