Article, Emergency Medicine

Digitally assisted bougie intubation: a novel technique for difficult airway management

Journal logoImprint logoCase Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

Digitally assisted bougie intubation: a novel technique for difficult airway management?

Abstract

Management of the difficult airway is a relatively common problem in emergency medicine. A popular adjunct technique is the use of a tracheal introducer (sometimes called a “bougie”). Blind digital intubation is also described. There is no discussion in the literature about the use of digital assistance for endotracheal tube delivery after successful laryngoscopy.

We report on 2 cases where a bougie was successfully placed by a di- rect laryngoscopy, but digital manipulation of bougie-endotracheal tube apparatus was required to overcome difficulty in advancing the tube past the vocal cords. This represents a potential Novel method to troubleshoot failure of endotracheal delivery using the bougie technique. Case 1 involves an 83-year-old woman intubated for respiratory fail- ure from influenza. Case 2 involved a 75-year-old man intubated during cardiac arrest. In both cases, a bougie was successfully placed into the trachea, but the ETT could not be advanced until digital manipulation of the bougie-ETT apparatus was performed. To our knowledge, these

are the first reported cases of this novel technique.

We propose the following algorithm when the intubating physician encounters a scenario where the bougie is in the trachea but the ETT will not advance: (1) optimize laryngoscope placement in the vallecula;

(2) pull the ETT back 2 cm, rotate counterclockwise, and attempt to ad- vance; and (3) consider removing the laryngoscope and introducing the index and middle fingers to guide the ETT into the trachea.

Management of the difficult airway is a relatively common problem

in emergency medicine [1]. The tracheal introducer (commonly called a “Gum elastic bougie” or “bougie”) can be a useful adjunct [2]. Blind dig- ital intubation is also described [3-5]. There is a single case report in the literature describing the use of a bougie to facilitate blind digital intuba- tion [6]. We report on 2 cases where a bougie was successfully placed under direct laryngoscopy, but digital manipulation of the bougie-ETT apparatus was used to overcome difficulty in advancing the tube.

An 83-year-old woman presented to the emergency department (ED) with influenza. Because of increased Work of breathing and desaturation, the patient was placed on noninvasive ventilation. After several hours on noninvasive ventilation, she was noted to be deterio- rating; a decision was made to proceed with rapid sequence intubation. Sequentially, Macintosh 3, Macintosh 4, and Glidescope techniques were used by 2 different emergency physicians, but no view of the vocal cords could be obtained and no attempt was made to pass an

? Support/disclosures: None.

ETT. The second emergency physician ultimately obtained a CL3 view with a Macintosh 4 blade, optimized with bimanual laryngoscopy. A bougie was passed, and its position was confirmed by both palpable clicks with passage over the tracheal rings and hold up with gentle ad- vancement into the tracheobronchial tree. A 7.5 ETT could not be passed over the bougie into the trachea despite rotation of the ETT and contin- ued laryngoscopy to maintain the position in the vallecula, optimizing alignment of the oral, pharyngeal, and laryngeal axes. A lubricated 7.0 ETT also could not be passed. Finally, a lubricated 6.5 ETT was intro- duced and could not be passed as attempts to advance the ETT were causing the apparatus to flex toward the posterior oropharynx. The emergency physician removed the laryngoscope and used 2 fingers to reinforce the bougie-ETT apparatus, and the tube passed into the tra- chea and was confirmed.

A 75-year-old man presented to the ED in cardiorespiratory arrest, and ACLS care was initiated. A large amount of feculent emesis was noted to obstruct the upper airway. A Macintosh 4 blade was used, and a CL3 view was obtained, but maintaining this view was made dif- ficult by the ongoing chest compressions. A bougie was passed into the trachea, and its position was confirmed in the same manner as in case 1. A 7.5 ETT was advanced over the bougie but was unable to be passed into the trachea despite the presence of the laryngoscope and attempted rotation of the ETT in both clockwise and counterclockwise directions. Before attempting to downsize the ETT, the emergency phy- sician removed the laryngoscope and introduced his index and middle fingers into the upper airway. The epiglottis and ETT were palpated, and the ETT was carefully advanced into the trachea under digital guid- ance. The endotracheal intubation was confirmed with condensation and bilateral breath sounds. Unfortunately, despite maximal efforts, the patient died approximately 1.5 hours later.

There are 2 published maneuvers to troubleshoot the scenarios that we encountered in which the ETT will not advance despite proper posi- tion of the bougie. If the laryngoscope is removed after placement of the bougie, the ETT may hang up on the arytenoid cartilage. Replacement of the laryngoscope may correct this problem. If the ETT still will not ad- vance, it is suggested that the ETT be withdrawn 2 cm and rotated coun- terclockwise [7]. The technique of digital manipulation of the apparatus adds a third maneuver to list of troubleshooting options when the ETT will not advance.

We propose the following stepwise troubleshooting algorithm when the intubating physician encounters the scenario where the bougie is in the trachea but the ETT will not advance: (1) optimize laryngoscope placement in the vallecula; (2) pull the ETT back 2 cm, rotate counter- clockwise 90?, and attempt to advance; and (3) consider removing the laryngoscope and introducing the index and middle fingers to guide the bougie-ETT apparatus into the trachea.

0735-6757/(C) 2015

Matthew Pirotte, MD Department of Emergency Medicine, Loyola University Medical Center, Maywood, IL, USA

Corresponding author. Department of Emergency Medicine, Loyola University Medical Center, 2160 S. First Ave, Maywood, IL 60153

Andrew Pirotte, MD

Department of Emergency Medicine, Northwestern Memorial Hospital,

Feinberg School of Medicine, Chicago, IL, USA

N. Seth Trueger, MD, MPH

Section of Emergency Medicine, University of Chicago, Chicago, IL, USA

http://dx.doi.org/10.1016/j.ajem.2015.04.052

References

  1. Brown III CA, Bair AE, Pallin DJ, Walls RM, NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med 2015;65(4):363-370.e1.
  2. Shah KH, Kwong B, Hazan A, Batista R, Newman DH, Wiener D. Difficulties with gum elastic bougie intubation in an academic emergency department. J Emerg Med 2011; 41(4):429-34.
  3. Cook Jr RT. Digital endotracheal intubation. Am J Emerg Med 1992;10(4): 396.
  4. Hardwick WC, Bluhm D. Digital intubation. J Emerg Med 1984;1(4):317-20.
  5. Tintinalli JE, Stapczynski JS. Tintinalli’s emergency medicine: a comprehensive study guide. 7th ed. New York: McGraw-Hill; 2011[xl, 2120 p].
  6. Rich JM. Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proceedings 2008;21(4): 397-9.
  7. McGill J. The bougie. HQMedEd: Vimeo; 2009.

Leave a Reply

Your email address will not be published. Required fields are marked *