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Technique

The Eschmann Stylet, also known as a “gum elastic bougie” or simply “bougie,” is a 60-cm long, flexible introducer that is designed to assist intubation of the anterior larynx, especially those with an “epiglottis-only” view. The tip of the bougie has an anterior fixed flexion with an angle of 40 degrees to facilitate entering an anterior glottic opening (see Fig. 22.43). Using a laryngoscope, one obtains the best view possible of the glottic opening. In the case of limited glottic view (see Fig. 22.44), the bougie is inserted such that the tip is introduced just under the epiglottis and probes for the glottic opening (see Fig. 22.45). The intubator should feel a tactile “pop” as the bougie enters the trachea, and he or she may also have a tactile sensation of “speed bumps” as the bougie is advanced and tracks across the tracheal cartilaginous rings (see Fig. 22.46). However, the more sensitive indicator of tracheal bougie position is the resistance encountered as the tip abuts against the carina, at approximately 27 to 30 cm. Should the bougie be inserted into the esophagus, no such endpoint is encountered.

FIGURE 22.43

Bougie Tip Shape. The bougie tip has a 30- to 35-degree bend to help facilitate entering the glottic opening when the glottis is not adequately visualized. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.44

Epiglottis-Only View. In this view, despite optimal laryngoscopy, the epiglottis may be all that is seen. The bougie may be a reasonable alternative in this situation. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.45

Bougie Under the Epiglottis. Here the bougie is hugging the underside of the epiglottis. Tracheal rings can be felt as “tactile speed bumps” confirming correct placement. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 22.46

Passing the Bougie. The two-person technique for using the bougie. Standard direct laryngoscopy is preformed, and the bougie is used like a stylet, but hugging the underside of the epiglottis. (Photo contributor: Lawrence B. Stack, MD.)

While continuing to hold anterior traction with the laryngoscope, the laryngoscopist should direct an assistant to thread the ETT over the bougie (see Fig. 22.47) again while maintaining anterior traction; the intubator should then advance the ETT over the bougie to the appropriate insertion depth. Resistance to tube advancement may indicate “arytenoid arrest” (see Fig. 22.48) and can be remedied by rotating the tube counter clockwise 90 degrees (see Fig. 22.49) followed by attempts to advance the ETT tip past the arytenoid cartilages.

FIGURE 22.47

Tube Over the Bougie. An assistant places the ...

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