The endotracheal tube introducer (also known as an introducer) and a tracheal tube bougie (also known as the bougie) have been effective, easy-to-use, and inexpensive adjuncts to difficult airway management for many years (Figure 22-1).1 Although newer devices such as the fiberoptic bronchoscopes and the video laryngoscopes are becoming more frequently used in the Emergency Department (ED) in difficult airway situations, skills pertaining to bougie insertion should be developed and maintained.2 They can be valuable if other intubating modalities are not readily available or the airway cannot be secured with direct laryngoscopy. It is recommended that a bougie be readily available in every ED.
Tracheal tube introducers and bougies. From top to bottom: Eschmann introducer, Frova intubating introducer, Muallem endotracheal tube stylet, S-guide with universal connector, Muallem endotracheal tube introducer, Rivier airway introducer, Cook airway exchange introducer 14 French, Cook airway exchange introducer 8 French, Cook tube exchanger, and Aintree intubation catheter. (Used with permission from reference 1.)
Airway management in the ED often occurs in an unpredictable and uncontrolled environment, sometimes with the patient arriving unannounced.3 Difficult intubation should be always anticipated and prepared for.3 The American Society of Anesthesiology defines a difficult intubation as an inability to properly insert an endotracheal tube with traditional direct laryngoscopy in three attempts or if intubation takes longer than 10 minutes.4 Difficult intubations usually reflect poor glottic visualization during direct laryngoscopy. A four-grade classification system by Cormack and Lehane describes the views of the laryngeal inlet during laryngoscopy.5 The exact incidence of difficult-to-intubate patients in the ED is difficult to extrapolate, with estimates ranging from 6% to 11%.6,7
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, anatomic variations, limited neck mobility due to cervical spine fractures and 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.8 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 these devices is the angled or coudé tip that can be aimed anteriorly and advanced under the epiglottis and into the trachea. Intubation with one of these devices was first described by MacIntosh in 1949.9 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.
The bougie or introducer is used to facilitate difficult intubation. It is a thin, long, cylindrical rod composed of rubber or plastic. ...