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The Case for Bougie Use on Every Intubation
ARTICLE IN PRESS Air Medical Journal 000 (2019) 1−2
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Feature Article
The Case for Bougie Use on Every Intubation Andrew H. Merelman, BS, NRP, FP-C * Rocky Vista University College of Osteopathic Medicine, Parker, CO
A B S T R A C T
Despite its value in emergency airway management, the endotracheal tube introducer, commonly known as the bougie, has traditionally been a point of disagreement between providers. It is typically viewed as a “rescue” device and not a primary airway tool. However, its value as a primary device during plan A has recently been recognized. Two studies have shown increased first-pass success using a bougie on the initial attempt. Additionally, bougie use on every intubation increases provider comfort with the device so that, on a truly difficult intubation, the skills and mechanics are instilled. In the out-of-hospital and critical care transport settings, intubation is often inherently more difficult because of varying environments. For these reasons, the bougie should be integrated into the first intubation attempt in emergent intubation. © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
The importance of first-pass intubation success as it relates to morbidity and mortality has been shown.1 Intubation success rates in the out-of-hospital setting are historically low.2 Two recent studies of supraglottic airway versus intubation in cardiac arrest showed initial intubation success rates of 52% and 79%.3,4 There are a number of contributing factors including challenging environments and training deficits. Intubation in the out-of-hospital and critical care transport settings may be inherently more difficult and require additional consideration.5,6 Airway difficulty is traditionally classified as either anatomic or physiological, but critical care transport providers are more likely to encounter situational difficulty as well. Although the bougie is primarily suited to address anatomic difficulty, it can reduce complications associated with physiological difficulty by decreasing the number of attempts and time to intubation. It may also address situational difficulty by making a potentially stressful procedure more relaxed. Any interventions that can improve first-pass success should be considered by critical care providers performing emergency airway management. The bougie is a valuable tool that makes intubation easier and can lead to improved first-pass success. Discussion The bougie is a controversial piece of equipment in emergency airway management. Opinions vary widely between providers because of differences in education and experience. The bougie is *Address for correspondence: Andrew H. Merelman, BS, NRP, FP-C, Rocky Vista University College of Osteopathic Medicine, 8401 South Chambers Road, Parker, CO 80134 E-mail address: [email protected] 1067-991X/$36.00 © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amj.2019.09.017
often considered a “backup” or “rescue” device and is traditionally not considered in initial planning. However, there has been a shift in practice because of a newfound appreciation of the tool. The conventional indication for a bougie is a Cormack-Lehane glottic view of 2B or 3A while performing direct or video laryngoscopy with a traditionally shaped blade (Macintosh or Miller). An endotracheal tube with a stylet should generally not be passed with a view worse than 2A because the tube is likely to obstruct the view or may not be able to negotiate the angle to the glottis. If a grade 3B or 4 view is present, intubation should not be attempted until the view can be optimized. A 2B view is defined as posterior cartilages but no vocal cords visible. A 3A view is defined as epiglottis lifted but no laryngeal cartilages visible. The bougie is useful in these situations tip helps navigate the upward angle into because the curved coude the glottic opening. However, this is only an effective option if the intubating clinician has experience with the bougie and is readily prepared to use it upon identification of a grade 2B or 3A view (Fig. 1). Using a bougie as plan B is feasible, but with the increasing focus on first-pass success, it is logical to use the approach most likely to be successful on the first attempt. Recently, two studies have shown an increased first-pass success with bougie use.7,8 Additionally, providers may be more likely to continue unsuccessful efforts9 because it can be psychologically challenging to abandon a plan that is expected to be successful.10 Including the bougie in plan A eliminates this possibility and increases the initial likelihood of success. The other significant benefit of bougie use on every intubation is that it is likely to improve provider competence with the device so that when it is truly required the mechanics and comfort are instilled.
ARTICLE IN PRESS 2
A.H. Merelman / Air Medical Journal 00 (2019) 1−2
Figure 1. Grade 3a versus 3b. (Reprinted with permission from openairway.org.) OpenAirway. Cormack-Lehane Grading Examples. https://openairway.org/cormack-lehane-grad ing-examples/ November 10, 2014. Accessed June 22, 2019.
Optimizing Bougie Success There are other advantages outside of allowing intubation of limited airway views including extra means of airway confirmation. The tip impacts first is the ability to feel the tracheal rings as the coude them. Although anecdotal reliability varies, studies have shown it to be present in most tracheal bougie placements.8,11 One way to maxi mize the chance of tracheal rings being felt is to ensure that the coude tip remains pointing upward, or anteriorly, as it is advanced down the trachea. Another method of confirmation is obtaining “holdup” as the bougie impacts the carina or lodges in a main stem bronchi. This confirmation technique has been cautioned against because of the risk of bronchopulmonary trauma. Despite the potential risk, holdup is a reliable method to help ensure correct placement12 because esophageal placement would elicit no holdup sign. If attempting to obtain holdup, advance the bougie as gently as possible and do not attempt to continue once resistance is met. Once the bougie is inserted, the laryngoscope should be left in place and the glottic view maintained as the endotracheal tube is advanced. This ensures the endotracheal tube reaches the intended destination and that the bougie has not dislodged. It also prevents collapse of airway tissues, which makes tube advancement more difficult. A common complication with tube delivery over a bougie is difficulty advancing the tip past the vocal cords. Typically, this occurs because the tip of the tube impacts the right vocal cord, right arytenoid, or posterior cartilages. This can be overcome by rotating the bougie 90 degrees counterclockwise as it is advanced toward the cords. This aligns the tip of the tube with the middle of the glottic opening and allows it to pass more easily. The bougie can be delivered alone, or any number of techniques with a preloaded endotracheal tube may be used. Preloaded techniques have been shown to result in similar success rates to nonpreloaded.13 Conclusion The bougie is an essential device for critical care providers performing emergency airway management. It allows patients to be
intubated with more restricted glottic views than a traditional endotracheal tube with stylet. The use of a bougie on every intubation improves the likelihood of first-pass success and increases operator comfort with the device. The device has a rare ability to address all types of difficulty. Providers should move this valuable tool from a “rescue” device into their routine practice.
References 1. Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20:71–78. 2. Myers L, Gallet C, Kolb L, et al. Determinants of success and failure in prehospital endotracheal intubation. West J Emerg Med. 2016;17:640–647. 3. Wang HE, Schmicker RH, Daya MR, et al. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-ofhospital cardiac arrest: a randomized clinical Trial. JAMA. 2018;320:769–778. 4. Benger JR, Kirby K, Black S, et al. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. JAMA. 2018;320:779–791. 5. Carlson J, Hostler D, Guyette F, et al. Derivation and validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): a predictive model for difficult intubation. West J Emerg Med. 2017;18:662–672. 6. Davis DP, Olvera DJ. HEAVEN criteria: derivation of a new difficult airway prediction tool. Air Med J. 2017;36:195–197. 7. Driver B, Dodd K, Klein LR, et al. The bougie and first-pass success in the emergency department. Ann Emerg Med. 2017;70. 473.e1-478.e1. 8. Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation a randomized clinical trial. JAMA. 2018;319:2179–2189. 9. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115:827–848. 10. Shaw J, Frerk C, Russell J. A commentary on human factors aspects of cases reported to NAP4. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. Major Complications in Airway Management in the United Kingdom. 2012:193–201. 11. Kidd J, Dyson A, Latto I. Successful difficult intubation: use of the gum elastic bougie. Anaesthesia. 1988;43:437–438. 12. Marson BA, Anderson E, Wilkes AR, et al. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia. 2014;69:219–223. 13. Baker J, Maskell K, Matlock A, et al. Comparison of preloaded bougie versus standard bougie technique for endotracheal intubation in a cadaveric model. West J Emerg Med. 2015;16:588–593.
Contents lists available at ScienceDirect
Air Medical Journal journal homepage: http://www.airmedicaljournal.com/
Feature Article
The Case for Bougie Use on Every Intubation Andrew H. Merelman, BS, NRP, FP-C * Rocky Vista University College of Osteopathic Medicine, Parker, CO
A B S T R A C T
Despite its value in emergency airway management, the endotracheal tube introducer, commonly known as the bougie, has traditionally been a point of disagreement between providers. It is typically viewed as a “rescue” device and not a primary airway tool. However, its value as a primary device during plan A has recently been recognized. Two studies have shown increased first-pass success using a bougie on the initial attempt. Additionally, bougie use on every intubation increases provider comfort with the device so that, on a truly difficult intubation, the skills and mechanics are instilled. In the out-of-hospital and critical care transport settings, intubation is often inherently more difficult because of varying environments. For these reasons, the bougie should be integrated into the first intubation attempt in emergent intubation. © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.
The importance of first-pass intubation success as it relates to morbidity and mortality has been shown.1 Intubation success rates in the out-of-hospital setting are historically low.2 Two recent studies of supraglottic airway versus intubation in cardiac arrest showed initial intubation success rates of 52% and 79%.3,4 There are a number of contributing factors including challenging environments and training deficits. Intubation in the out-of-hospital and critical care transport settings may be inherently more difficult and require additional consideration.5,6 Airway difficulty is traditionally classified as either anatomic or physiological, but critical care transport providers are more likely to encounter situational difficulty as well. Although the bougie is primarily suited to address anatomic difficulty, it can reduce complications associated with physiological difficulty by decreasing the number of attempts and time to intubation. It may also address situational difficulty by making a potentially stressful procedure more relaxed. Any interventions that can improve first-pass success should be considered by critical care providers performing emergency airway management. The bougie is a valuable tool that makes intubation easier and can lead to improved first-pass success. Discussion The bougie is a controversial piece of equipment in emergency airway management. Opinions vary widely between providers because of differences in education and experience. The bougie is *Address for correspondence: Andrew H. Merelman, BS, NRP, FP-C, Rocky Vista University College of Osteopathic Medicine, 8401 South Chambers Road, Parker, CO 80134 E-mail address: [email protected] 1067-991X/$36.00 © 2019 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.amj.2019.09.017
often considered a “backup” or “rescue” device and is traditionally not considered in initial planning. However, there has been a shift in practice because of a newfound appreciation of the tool. The conventional indication for a bougie is a Cormack-Lehane glottic view of 2B or 3A while performing direct or video laryngoscopy with a traditionally shaped blade (Macintosh or Miller). An endotracheal tube with a stylet should generally not be passed with a view worse than 2A because the tube is likely to obstruct the view or may not be able to negotiate the angle to the glottis. If a grade 3B or 4 view is present, intubation should not be attempted until the view can be optimized. A 2B view is defined as posterior cartilages but no vocal cords visible. A 3A view is defined as epiglottis lifted but no laryngeal cartilages visible. The bougie is useful in these situations tip helps navigate the upward angle into because the curved coude the glottic opening. However, this is only an effective option if the intubating clinician has experience with the bougie and is readily prepared to use it upon identification of a grade 2B or 3A view (Fig. 1). Using a bougie as plan B is feasible, but with the increasing focus on first-pass success, it is logical to use the approach most likely to be successful on the first attempt. Recently, two studies have shown an increased first-pass success with bougie use.7,8 Additionally, providers may be more likely to continue unsuccessful efforts9 because it can be psychologically challenging to abandon a plan that is expected to be successful.10 Including the bougie in plan A eliminates this possibility and increases the initial likelihood of success. The other significant benefit of bougie use on every intubation is that it is likely to improve provider competence with the device so that when it is truly required the mechanics and comfort are instilled.
ARTICLE IN PRESS 2
A.H. Merelman / Air Medical Journal 00 (2019) 1−2
Figure 1. Grade 3a versus 3b. (Reprinted with permission from openairway.org.) OpenAirway. Cormack-Lehane Grading Examples. https://openairway.org/cormack-lehane-grad ing-examples/ November 10, 2014. Accessed June 22, 2019.
Optimizing Bougie Success There are other advantages outside of allowing intubation of limited airway views including extra means of airway confirmation. The tip impacts first is the ability to feel the tracheal rings as the coude them. Although anecdotal reliability varies, studies have shown it to be present in most tracheal bougie placements.8,11 One way to maxi mize the chance of tracheal rings being felt is to ensure that the coude tip remains pointing upward, or anteriorly, as it is advanced down the trachea. Another method of confirmation is obtaining “holdup” as the bougie impacts the carina or lodges in a main stem bronchi. This confirmation technique has been cautioned against because of the risk of bronchopulmonary trauma. Despite the potential risk, holdup is a reliable method to help ensure correct placement12 because esophageal placement would elicit no holdup sign. If attempting to obtain holdup, advance the bougie as gently as possible and do not attempt to continue once resistance is met. Once the bougie is inserted, the laryngoscope should be left in place and the glottic view maintained as the endotracheal tube is advanced. This ensures the endotracheal tube reaches the intended destination and that the bougie has not dislodged. It also prevents collapse of airway tissues, which makes tube advancement more difficult. A common complication with tube delivery over a bougie is difficulty advancing the tip past the vocal cords. Typically, this occurs because the tip of the tube impacts the right vocal cord, right arytenoid, or posterior cartilages. This can be overcome by rotating the bougie 90 degrees counterclockwise as it is advanced toward the cords. This aligns the tip of the tube with the middle of the glottic opening and allows it to pass more easily. The bougie can be delivered alone, or any number of techniques with a preloaded endotracheal tube may be used. Preloaded techniques have been shown to result in similar success rates to nonpreloaded.13 Conclusion The bougie is an essential device for critical care providers performing emergency airway management. It allows patients to be
intubated with more restricted glottic views than a traditional endotracheal tube with stylet. The use of a bougie on every intubation improves the likelihood of first-pass success and increases operator comfort with the device. The device has a rare ability to address all types of difficulty. Providers should move this valuable tool from a “rescue” device into their routine practice.
References 1. Sakles JC, Chiu S, Mosier J, et al. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20:71–78. 2. Myers L, Gallet C, Kolb L, et al. Determinants of success and failure in prehospital endotracheal intubation. West J Emerg Med. 2016;17:640–647. 3. Wang HE, Schmicker RH, Daya MR, et al. Effect of a strategy of initial laryngeal tube insertion vs endotracheal intubation on 72-hour survival in adults with out-ofhospital cardiac arrest: a randomized clinical Trial. JAMA. 2018;320:769–778. 4. Benger JR, Kirby K, Black S, et al. Effect of a strategy of a supraglottic airway device vs tracheal intubation during out-of-hospital cardiac arrest on functional outcome: the AIRWAYS-2 randomized clinical trial. JAMA. 2018;320:779–791. 5. Carlson J, Hostler D, Guyette F, et al. Derivation and validation of The Prehospital Difficult Airway IdentificationTool (PreDAIT): a predictive model for difficult intubation. West J Emerg Med. 2017;18:662–672. 6. Davis DP, Olvera DJ. HEAVEN criteria: derivation of a new difficult airway prediction tool. Air Med J. 2017;36:195–197. 7. Driver B, Dodd K, Klein LR, et al. The bougie and first-pass success in the emergency department. Ann Emerg Med. 2017;70. 473.e1-478.e1. 8. Driver BE, Prekker ME, Klein LR, et al. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation a randomized clinical trial. JAMA. 2018;319:2179–2189. 9. Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115:827–848. 10. Shaw J, Frerk C, Russell J. A commentary on human factors aspects of cases reported to NAP4. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. Major Complications in Airway Management in the United Kingdom. 2012:193–201. 11. Kidd J, Dyson A, Latto I. Successful difficult intubation: use of the gum elastic bougie. Anaesthesia. 1988;43:437–438. 12. Marson BA, Anderson E, Wilkes AR, et al. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia. 2014;69:219–223. 13. Baker J, Maskell K, Matlock A, et al. Comparison of preloaded bougie versus standard bougie technique for endotracheal intubation in a cadaveric model. West J Emerg Med. 2015;16:588–593.