The bougie is also known as:

• Gum elastic bougie

• Eschmann stylet

• Intubating or endotracheal tube introducer

 

The bougie is a solid or hollow, semi-malleble stylet that can be blindly guided into the trachea.  This device can be especially helpful when only the epiglottis or arytenoids can be visualized during laryngoscopy.  The bougie can also be used blindly when any view of the glottis is obscured.  In a situation where visualizing the vocal cords is difficult, the bougie is directed posterior to the epiglottis, with the curved tip angled anteriorly.  Using the bougie as a guide, the endotracheal tube is passed over it into the desired position.

 

The typical bougie is 60 cm (24 in) long, 15 French (5 mm diameter) with a 35-40 degree “hockey-stick” angle approximately 3.5cm from the end.  This may also be called a “coude” tip.  Most devices have external distance markings.  Some types have a central lumen that can be used for ventilation and/or aspiration.  A bougie may be disposable (single-use) or re-usable.  A smaller size bougie (10French) can be used for 4.0 to 5.5mm ETT.  A bougie should ALWAYS be IMMEDIATELY available in any setting where anesthesia is being provided.

 

The bougie provides a unique combination of stiffness and flexibility at body temperature.  This flexibility makes damage to vocal cords or trachea unlikely as the introducer will bend if undue force is applied in the face of resistance.

 

TECHNIQUE

While the clinician is performing laryngoscopy, the bougie should be held 20-30cm proximal to the coude tip, inserted into the oropharynx, and rotated so that the angled segment is directed anteriorly toward the larynx.  Once the bougie has entered the trachea, a distinctive “clicking” should be felt as the tip passes over the cartilaginous rings of the trachea.

 

The bougie can then be used as a guide over which the endotracheal tube can be passed.  There should be resistance or a “hold-up” at approximately 30-40cm depth as the clinician encounters the carina; if this does not occur, the bougie is likely in the esophagus.  The view of the bougie and any visible airway structures should be maintained while the ETT is passed.  The ETT should be introduced through the cords, over the bougie, using a 90 degree counter-clockwise rotation to prevent the beveled edge of the ETT from getting caught in the arythenoids.  The bougie can then be removed and confirmation of the ETT obtained.

 

The “Kiwi grip” can be used by a solo clinician; the bougie is curled upon itself and pre-loaded with an ETT.

 

Light wands can also be used like a bougie.  They have lighted tips and can be passed blindly into the airway.  If correctly placed in the trachea, the anterior neck will be illuminated.  An ETT can then be passed over the wand into the trachea.