Tag Archives: bougie

VLVids: Intubation in Spinal Immobilisation

Clinical video demonstrating a collection of techniques to facilitate elective intubation for a patient with an unstable cervical spinal injury in caliper traction.  Note the sideways introduction of the VL blade due to limited space for the VL handle, optimisation of the view (‘Rule of 3’), use of a coude-tipped bougie (introducer), and the 3-part technique to advance the endotracheal tube when it catches on the arytenoid cartilage (pull tube back to disengage, rotate 90 degrees counterclockwise, advance tube).

VLVids: Room for Improvement!

This real-life videolaryngoscopy example (RSI of a patient with a head injury for craniectomy) shows some commom errors, and room for improvement. Three major areas that could be better to spot here:

  1. Less-than-ideal positioning of the VL blade. The tip is too deep (over the epiglottis, rather than in the vallecula), which reduces the available space to manipulate both VL and ETT, the field of vision, and the ability to perceive the approach of the ETT.
  2. Quick suctioning of the secretions/saliva/mucus would reduce the risk of losing the view or the patient aspirating.
  3. An introducer (stylet/bougie) would greatly assist passage of the ETT through the cords.

VLVids: Use an introducer!

A classic example of good videolaryngoscopy technique being thwarted by not always using an introducer (stylet or bougie).  Note the clinician performing the intubation gets perfect, optimised VL view (Rule of 3), but then struggles to pass the ETT anteriorly enough, losing time.  Although this was no problem for the well-oxygenated patient in this case (and the intubation is still under 45 seconds duration), in a critical case it can lead to desaturation, frustration, and possible intubation trauma.

Four methods of endotracheal tube passage in simulated airways – Poster from ICEM 2016

Here’s the poster by Kingma, Hofmeyr, Zeng, Cooramasamy and Brainard that has generated a fair amount of interest (>10k impressions on Twitter).  Full analysis hopefully coming soon to a journal near you.  Bottom line?  In a difficult airway, you’d best be using a bougie or stylet, no matter who you are.  As far as bougies go, preloading rather than railroading is faster and seems better.  Click on the image for a full-resolution PDF (2Mb).

Four_Methods_ETI_Poster_ICEM_2016

Want to talk about this?  Comment below or ping @surferkirst @rosshofmeyr @TheSharpEndCrew on Twitter!

Bougie-assisted intubation snagging on arytenoid

This common problem is worst with small bougies, such as in this paediatric example of a child with severe burns and a difficult airway.  The bevel of the ETT allows the tip of the tube to stick out right (laterally) of the bougie and snag on the right arytenoid cartilage.  This can be remedied by withdrawing the ETT slightly (to disengage it from the arytenoid), effecting a one-quarter counter-clockwise rotation of the ETT on the bougie (bringing the bevel and tip of the ETT into a superior midline position snug with the bougie), and then advancing again.