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Wanna Bougie?: Four Steps to Bougie-Assisted Difficult Intubation

Braude, Darren MD, EMT-P

doi: 10.1097/01.EEM.0000360602.73300.da
The Emergency Airway

Dr. Braude is an associate professor of emergency medicine at the University of New Mexico School of Medicine, the medical director for PHI Air Medical of New Mexico, both in Albuquerque, a co-director of Airway911 and the National Procedural Sedation Course (, and the author of a new book, Rapid Sequence Intubation, now available at

If anyone made a bougie quiver you could wear on your back, I would probably own one. It still surprises me to hear of EDs that don't even stock a bougie, let alone use them routinely. Perhaps I practice in an alternate universe, but we have a bougie on the patient's chest for most ED intubations, and they are in every OR and on every crash cart in the hospital. We no longer bother to compile stories about lives they have saved; there are just too many of them.

The endotracheal tube introducer, aka gum elastic bougie, is an aid for difficult intubations, particularly in cases of extremely anterior larynx where even the posterior cartilages cannot be visualized despite optimal positioning and external laryngeal manipulation. A bougie is a semi-rigid device, 60 to 70 cm in length with an angled “coude” tip that looks like a long, flexible, stylet or heavy-duty tube exchanger. Bougies are manufactured stiff enough to be easily directed at the tip yet flexible enough for an endotracheal tube to pass over freely.

The bougie may be shaped slightly (recommended), but not nearly to the extent of a stylet. Both reusable and disposable devices are available as are adult (accommodate a 6-0 or larger tube) and pediatric versions (accommodate a 4-0 or larger tube). There are even introducers that allow for oxygenation through the device during insertion and end-tidal CO2 detection.

The bougie is most useful in a Cormack-Lehane Grade 3 airway when only the epiglottis can be visualized so that the “approximate” position of the larynx can be ascertained. In this situation, the bougie is advanced in the mid-line under the epiglottis and directed anteriorly. The tip is placed “semi-blindly” into the trachea or where the trachea is likely to be, with reduction of cricoid pressure as necessary. Tracheal position is then confirmed by the palpation of “clicks” as the distal bent tip passes over each tracheal ring or the inability to pass it beyond 40 cm in an adult, indicating that it has been held up at the carina or in a bronchus, as opposed to passing freely into the stomach.

Studies suggest that tracheal “clicks” may be appreciated up to 90 percent of the time, though I personally believe it is more like 50 percent at best. Once tracheal positioning is confirmed, an endotracheal tube is passed into the trachea over the bougie, while the laryngoscope is maintained in place to create a free channel behind the tongue. Tube passage often requires gentle pressure with a 90-degree counterclockwise tube rotation to negotiate the larynx.

The bougie also may be useful in cases where the vocal cords are well visualized at laryngoscopy but the selected tube will not pass, either because of the stylet shape, the size of tube selected, airway swelling, or obstruction with a tumor. In these cases, the bougie may be used as a placeholder, and a more appropriate size tube selected and passed gently over the bougie. This averts the need for the intubator to pull out or take their eyes off the glottis and potentially lose the view.

The bougie is generally not a good technique for failed airways with significant hypoxemia because of time delays involved. Practicing with the bougie on easy intubations and having it immediately available can minimize these delays when it is really needed. Some EMS services and air medical programs have begun using the bougie in all first intubations in place of a stylet to gain experience with the device and to save time. (If it is good for a difficult airway, why wait to find out the airway is difficult?) The bougie also may be used for tube confirmation, tube exchange (70 cm versions) when a tube exchanger is not available, surgical airways, and to facilitate endotracheal intubation through some extraglottic devices.

Introducers are relatively inexpensive and surprisingly easy to use. My colleagues and I offer a free, online multimedia module on use of the bougie for all four primary indications on our web site at

© 2009 Lippincott Williams & Wilkins, Inc.