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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.
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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.
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