Tricks of Bougie

Q: Endotracheal tube (ETT) introducer, popularly known as a 'Bougie ', should not be bent more than? - select one

A) 10 degrees

B) 30 degrees

C) 45 degrees

Answer: B

Three tricks to use Bougie successfully are:

1. Lubricating the lower part of the bougie. This may help the ETT to pass over. Avoid lubricating the part the operator will hold, as it may make it difficult to grasp and control.

2. Enter the bougie and try to keep it in the right corner of the mouth, while keeping the angle of approach to the larynx, and stay as anterior as possible. The objective is to avoid the midline and the incisors. Often, when entering the midline, it may get stuck at the base of the tongue and track posteriorly into the hypopharynx.

3. Bending the introducer at the distal level, depending on the view (from partially visible to the completely obscure view of the vocal cord), to about 10-20 cm. This allows the bougie to curve around the base of the tongue to travel towards the larynx. Some operators "hit-up" the bougie by stripping it firmly between the thumb and finger at about 15 cm from the distal tip. The friction from this maneuver heats up and stretches the material, while inducing a bend. 

The bend should never exceed 30 degrees (choice B); otherwise, the distal coudé tip will angle too anteriorly and may catch on the tracheal rings.

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References:

1. Sime J, Bailitz J, Moskoff J. The bougie: an inexpensive lifesaving airway device. J Emerg Med. 2012 Dec;43(6):e393-5. doi: 10.1016/j.jemermed.2010.11.053. Epub 2011 May 7. PMID: 21550750.

2. Shekhar AC, Altman-Ezzard M, Kimbrell J, Stebel J, Ashley E, Mitra A, Friedmann T, Abbott EE, Strother C, Kutzin J. Flexible Tip Bougie for Emergency Tracheal Intubation by Paramedics and Emergency Physicians. Air Med J. 2025 Jan-Feb;44(1):67-69. doi: 10.1016/j.amj.2024.11.013. Epub 2024 Dec 22. PMID: 39993863; PMCID: PMC12266224.

3. Bougie for Difficult Intubation - https://www.youtube.com/watch?v=Q9MlXl3NIzk