Difficulty Managing a Patient's Airway? Bougie Tips and More

Robert D. Glatter, MD; Amy Faith Ho, MD


March 18, 2019

This transcript has been edited for clarity.

Robert D. Glatter, MD: Managing a difficult airway can be a stressful experience not only for physicians but for all members of the clinical care team. Being prepared for these difficult situations can make all the difference when you're confronted with challenging patients in the emergency department (ED). Here to teach us some useful techniques to better manage these challenging patients is Dr Amy Faith Ho, assistant medical director and clinical faculty at John Peter Smith Hospital in Fort Worth, Texas. Welcome, Dr Ho.

Amy Faith Ho, MD: Thank you so much for having me, Dr Glatter.

The Bougie Airway Device

Glatter: First up is the bougie airway management device, something we see all the time. It's in our ED, and although we don't use it every day, we are looking to your expertise on how we can better use it when we need to.

Dr Ho's colleague showing the anterior bend at the 10-cm mark

Ho: We talk about the bougie all the time in terms of difficult airways, but it's very rare that we actually use it. My recommendation is to play around with the bougie and use it for nondifficult airways so you get comfortable with it.[1] The bougie is thin, rigid, and easy to insert, and it has a little anterior bend, which is what makes it so good for placing anterior airways.

I do not like to load the endotracheal (ET) tube onto the bougie beforehand. I'll have someone help me load the tube once I have the bougie in between the cords, because the tactile response you get from this rigid plastic is so much better without the ET tube on the gullet. The bougie already has the little anterior bend. But at the 10-cm mark, I add another anterior bend, which it holds nicely. That gets you right to the rings, so you can feel them as you're going down.

I believe it's good to experiment with different grips to find what you're most comfortable with. Almost always I see people holding it like a pencil, which is fine except it's a little floppy; the bougie may be lubricated sometimes and it tends to flail about. My favorite is the curve-around grip. I curve the entire bougie around.

Curve-around (cross) grip

You can hold it where the tube crosses itself and it is not going to go anywhere no matter how much lubrication or how hard you're pushing. You also can load the ET tube onto the bougie, if that's your preference. Then you can use the end of the tube to hold that curve. You thread the ET tube onto the bougie; there's a small hole right at the very end of the ET tube. And you can curve the bougie around and place the end of the bougie through that hole. This helps maintain your cross as you get into the airway.

Of course, you don't have to use the curve-around grip. I have small hands, so that's what works best for me. Another grip is similar to a hang-ten sign. You use your three middle fingers to hold the tube and your pinky and thumb to splint it. That's also a very strong grip, so you're not going to worry about the bougie moving.

Dr Ho demonstrating the use of an ET tube on a bougie

The bougie has many uses, but for any airway that's going to be tight, for an anterior airway or abnormal anatomy, the bougie should be in your back pocket.

Glatter: That's a great summary. When we're in a situation where we need to grab a bougie, we may not be thinking about these things, so these are excellent points to make ahead of time. In terms of the names of the grips. Would you say that last grip is also called the shaka?

Hang-ten (shaka) grip

Ho: Yes, the shaka grip. There are a number of different bougie grips. As far as I'm concerned, you should know that there's one that you loop around, there's the pencil grip, and then there's the hang-ten, or shaka, grip.

Glatter: Let's troubleshoot. Say you're using the bougie and you don't feel those vibrations from the trachea. What would be the first thing to consider when you think you're on the trachea but you don't feel the vibrations? Is the position of the bougie possibly the issue?

Ho: It can be. The bougie tip may be a bit to the side and you're not feeling it as much. It also could be that you're feeling a bit of an adrenaline rush so you're not feeling that response yourself. I usually say, if you think you're in but you're not certain, throw in another tube. If you're in the esophagus and you intubate with a second tube, you're probably going to get that one into the airway.

Glatter: So, in the heat of the moment, you just can't feel the vibrations of the tracheal ring. What else would you consider in that situation? Could it be the positioning of the distal tip, that it's not anterior?

Ho: That absolutely could happen. The tube could be turned a bit posteriorly. Maybe you got it in and then it rotated. All of those are possibilities. So, what do you do? You can rotate your grip approximately 90˚ and see if you feel any difference. Or you can go ahead and thread a tube and see what happens. That's actually a good setup for doing a double intubation, even if you're in the esophagus.

Blind Digital Intubation

Glatter: Before we talk more about that, I do want to discuss another important technique known as digital intubation, something we may not think about. When a patient is coding and you need to intubate, obviously the patient may not have a gag reflex. This also applies to patients with lots of secretions, blood, and vomit.

Ho: Digital intubation is absolutely my favorite technique for when there's massive vomiting or the field is very bloody.[2,3] I think we've all been there. You can't see anything even with direct laryngoscopy (DL) or video laryngoscopy (VL). You're going in blind. This is when it's important to understand the anatomy.

I use a model of the airway to teach this technique. In front is the trachea, in back is the esophagus. From the inside, the epiglottis is just anterior to the airway, and then at the top, which is posterior, is the esophagus. I approach the patient from the front. If the patient is lying down, I'm above them, and my hips are at their hips. I'm not behind them.

Positioning the middle finger on the epiglottis

I use my nondominant hand and insert my middle finger, which for me is the longest finger, and I push the epiglottis even more anteriorly. You can actually get your hand fairly far inside. If you have small hands, you can get in past the knuckles; if you have large hands, usually you'll just be able to reach the epiglottis. When I have the epiglottis pushed really anterior, I use my index finger to guide the ET tube down. You can take the ET tube, push it through, and then you can use your index finger to guide it down. That is digital intubation. You should be able to feel the tube go down, sandwiched between your index and your middle finger. You can use the other hand to kind of load it forward.

ET tube sandwiched between the index and middle finger

Glatter: Would you suggest starting with a bougie?

Ho: I always use the bougie for these because they typically are situations where things didn't go perfectly to start with, so it's not ever going to be your first attempt. I always use the bougie because it's smaller. And then you can decide whether you can squeeze in an 8-0 tube or if you have to go smaller.

Glatter: Any thoughts about using a meconium aspirator? I know we've discussed this offline. Have you ever considered using that when you have massive secretions, an upper GI bleed?

Ho: I have thought about this a lot, and personally, I don't like to rely on equipment that's not always going to be there. If I asked for a meconium aspirator in my ED, there would be a lot of blank stares. So, I believe in either just buying one of the commercial large-bore suctions (and frankly, I don't think any of them are that great for the chunky burrito vomit), or know your blind techniques as an adjunct. You can also always just use suction without the Yankauer tip; sometimes I'll use two of those and have someone hold them in the mouth for me, to try to suction so that I can see.

Glatter: Do you think people have some fear about putting their fingers into someone's oral cavity? Is that one of the reasons behind the reluctance to do a digital intubation?

Ho: I think people don't realize that they can actually reach the epiglottis. I believe that's the biggest block. I usually wear surgical gloves if I'm going to do this, primarily because they're a little thicker. I don't like to rely on the thin gloves. But remember, this will be your second or third pass on a difficult airway.

Double Intubation

Glatter: Which brings us to the double intubation. Obviously, if you've intubated the esophagus and you know that's where the tube is, maybe you should keep that tube in there.

Ho: This is great for massive vomit or blood, because when we get a tube into the esophagus, we can see what happens. It's when you're not obviously in the esophagus that it can be a problem. What I tell people is, don't pull out the tube.

I do inflate the cuff of the tube that's inserted and then try to intubate using DL, VL, or whatever I was using with the bougie. Assume there's already something in the esophagus and the balloon is inflated. Nothing is going to go down that end, and usually you can maneuver the tube into the trachea. I've found that this is helpful when you are working blind. Of course, you do need some oxygenation. You can't do this when the patient's oxygen is at 80%, but if they are in the middle 90% area of O2, this is an incredibly reasonable thing to try.

Glatter: Suppose you have a patient with angioedema. Let's say you're already in the esophagus; would it then be reasonable to go for the airway with the bougie?

Ho: Angioedema is a tough one. I'm always a little worried about traumatizing the airway and creating more swelling, so it depends on how tight things are. Truly, for angioedema I would prefer to either go in initially with a bougie or even try awake intubation with fiber optics, because that's a slightly different scenario. This scenario is more for when you're going in blind but the anatomy is either fairly normal in terms of patency or may be abnormal laterally with masses or cancer but not actually less patent.

Retrograde Intubation

Glatter: Finally, I want to talk about retrograde intubation, which many people may not even think about. With DL and VL, and with optics being so stellar right now, people don't think about retrograde intubation, but there are situations where you definitely would consider it.[4] What are your thoughts?

Retrograde kit

Ho: I agree. I've performed cricothyrotomy a few times in my career but they are just a bloody mess. You have to have surgical backup and that sort of thing. So I believe that retrograde intubation is a great, less invasive approach when you're in that cric area. But remember, this is not a crash technique. You cannot get this done in 5 or 10 seconds as you can with a cric. You need approximately a minute and you also need a partner, someone who can help you with retrograde intubation. I only consider this procedure if it's a patient who maybe would need a cric but I have a little more time. The easiest patient to think of is an ENT cancer patient who's crashing but you were able to oxygenate to some extent. In this case, retrograde intubation would be reasonable to try before you cric. In the worst-case scenario, you could convert to a cric.

A video demonstrating retrograde intubation is also available on Vimeo.

The actual technique is interesting, although I think it's falling out of favor. The equipment you need is pretty basic. You can buy a retrograde intubation kit, but really all you need is a central line kit. The intubation kit comes with a couple of basic items. It usually includes some forceps, a wire that looks just like a central line wire, and usually a needle in a catheter. But all you need really is the angiocath from the central line set-up, the wire, and a partner to help you.

Inserting a needle into the cricothyroid membrane

Retrograde intubation is similar to what you do for a cric. You take a needle with water or normal saline in it, and you go right into the cricothyroid membrane. As you're doing this, you're aspirating. Once you're into the airway you'll see bubbles, so you know you're in the airway.

Then you can go ahead and advance the angiocath. The angiocath should be directed superiorly, so it's going up toward the head.

When advancing the angiocath, direct it superiorly

Then you thread the wire into the angiocath going superiorly. That's when you need someone who will catch it on the other end, so they need to be at the mouth and ready to fish out this wire. They can use Magill forceps or their hand. I'm a big fan of just using your hand. The wire comes up through the throat and into the mouth. Someone needs to catch it and pull it up. Then you thread the ET tube all the way down into the airway. It's pretty simple. You can easily get this done within 60 seconds, but you do need 60 seconds.

Glatter: Do you usually put a clamp at the base, just to keep it stationary?

Ho: Absolutely. That's when I use the hemostat. I will clamp it right at the neck where the wire is coming out or I'll have someone reliable hold it right there.

Glatter: I have heard that the tube can flip into the esophagus. You're almost there, it's in the trachea, but somehow it flips out. Perhaps when you're pulling the wire out, somehow it dislodges the tube.

Ho: I've heard about this too. I've never had it happen but I've heard that it happens. I think as long as you have the wire all the way through and secured, it would be quite unusual because the wire is all the way out of the mouth with a direct path to the cricothyroid membrane. It would be weird for it to slip into the esophagus unless you lost the wire outside the neck. I have heard of people having difficulty being able to grab it, as the wire is coming up through the angiocath, coming out through the cords. For example, especially with angioedema, really bad swelling, it may be that it just can't get through that small area. Then you just convert to a cric.

A second person needs to grab the threaded wire

Glatter: I also have seen the tube coming out through the nares and not through the oral cavity. In your experience, does the wire come preferentially through the nasal cavity as opposed to the oral pharynx?

Ho: Yes, it can. That's why the partner is so important, because your partner is going to grab the wire the moment they see it in the oral pharynx.

I would usually prefer not to use the nasal technique because, in my opinion, that will take a bit longer, but it can happen. In the worst case, if it does come out of the nares, you can intubate from there as well. My preference is always oral pharynx.

Glatter: Any other pearls you have for us?

Ho: For retrograde intubation, tell people what you're doing beforehand, because it's going to be unusual. And then make sure that whoever is going to fish the wire from the mouth knows their job. That's probably one of the most important things. Again, it's impossible to do if you're by yourself, but you can have a nurse or someone else help, someone who is comfortable with the oropharyngeal anatomy.

Glatter: This is great. Your models and all of the demonstrations are critical. Thank you so much for taking the time out of your schedule to do this.

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