Morning Report: 10/18/2013

Thanks to Dr. Shin for today’s Morning Report!

The Bougie

Uses of the Bougie

• Assistance in endotracheal intubation, especially difficult airways
  • Glidescope caveats
    • The angle of the bougie that we have will not work in a glidescope assisted intubation unless we bend the bougie appropriately to match the angle of the glidescope’s optics
• Tracheal Intubation with an LMA in place
• Surgical airway
• Selective endobronchial intubation
  • Rotate the bougie tip to the side you want to selectively intubate
• Confirmation of endotracheal tube position
• Endotracheal tube exchange
• Intercostal catheter insertion
  • Seldinger technique using the straight end in obese patients

How to use the bougie appropriately in endotracheal intubation

• the bougie is typically held by the intubator 20- 30  cm proximal to the coude tip
• the bougie should be inserted via the side of the mouth, rather then down the center, so that rotation of the bougie provides better control of the coude tip in the vertical plane
• it is typically inserted directly into the trachea and then used as a guide over which the endotracheal tube can be placed using the Seldinger technique.
• it can be preloaded with an endotracheal tube or an assistant can pass the endotracheal tube over the free end of bougie while the intubator maintains visualization of the bougie/ cords and ensures the placement of the bougie remains secure
• the assistant should continuously walk their hands down the bougie as the endotracheal tube is advanced over it
• the tracheal tube should be introduced through the cords, over the bougie, using a 90º counter clockwise rotation to prevent its beveled point from getting caught in the arytenoids
• the user should feel the tip of the bougie ‘click’ as it passes along the tracheal rings
• when used to confirm endotracheal placement the bougie is passed down the endotracheal tube and there should be ‘hold up’(when it hits the carina) at 30-40cm depth, if this does not occur the bougie is likely to be in the esophagus.
• the bougie may be passed into one of the main bronchi by twisting the angled tip in the preferred direction, this may be useful to facilitate endobronchial intubation (e.g. in massive hemoptysis where other equipment is unavailable)

http://lifeinthefastlane.com/education/ccc/bougie/

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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