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Airway management in the Emergency Department often occurs in an unpredictable and uncontrolled environment, sometimes with the patient arriving unannounced.1 The American Society of Anesthesiology defines a difficult intubation as an inability to properly insert an endotracheal tube with traditional direct laryngoscopy within three attempts or if it takes longer than 10 minutes.2 Difficult intubations usually reflect poor glottic visualization during direct laryngoscopy. A four-grade classification system by Cormack and Lehane describe the views of the laryngeal inlet during laryngoscopy.3 The exact incidence of difficult to intubate patients in the Emergency Department is difficult to extrapolate but estimates range between 6% and 11%.4,5

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Difficulties arise when the vocal cords cannot be fully visualized due to airway distortion (e.g., edema, expanding hematomas, radiation, surgery, or trauma), airway masses, anatomical variations, cervical collars, deformities of the head and neck, orofacial injuries, or oropharyngeal blood and secretions. One study reported that the vocal cords could not be visualized in 22% of patients wearing a cervical collar.6 This failure to visualize the glottis can make intubation difficult or impossible. The intubating introducer, tracheal tube introducer, or bougie can be a good rescue device in these situations. The main advantage of many of these devices is their angled or coudé tip that can be aimed anteriorly, advanced under the epiglottis, and into the trachea. Intubation with one of these devices was first described by Macintosh in 1949.7 The device he used was a 60 cm long, 15 French, elastic catheter with a J or coudé tip that was bent 40° at the distal end.

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This chapter reviews the general principles for using tracheal tube introducers, intubating introducers, and bougies; as well as reviewing some of the more commonly available devices. The terms tracheal tube introducers, intubating introducers, and bougies are often used interchangeably. This chapter uses the term bougie unless some other term is specific to a manufacturer's device.

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The bougie is intended to facilitate endotracheal intubation in patients where visualization of the glottis is difficult or inadequate despite external laryngeal manipulation and optimal patient positioning. The most frequent indication for the use of a bougie is the inability to intubate endotracheally using traditional direct laryngoscopy. It can also be used for “routine intubations.” The narrower and more flexible bougie, compared to an endotracheal tube, can easily be inserted into the trachea when the glottis is visualized during direct laryngoscopy and the endotracheal tube inserted then advanced over the bougie. A bougie can be inserted directly into the trachea or through a supraglottic airway device to facilitate endotracheal intubation. A bougie may be inserted when the glottic opening is visible, but the endotracheal tube will not pass through the vocal cords. The bougie serves as a placeholder in these cases and avoids the need to remove the laryngoscope and re-perform direct laryngoscopy when the bougie is available. The use of a bougie to intubate the ...

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