Airway bougies

[RedAnesthesia]

I've been put in charge of finding bougies for my group. I'm new to my group and I'm big proponent of using bougies with difficult airways. Somehow my group hasn't ever had them before. I'm curious as to what brand you guys have in your groups? Just for clarification, I'm not asking about long cook exchange catheters, but the gum elastic bougies with bent tip.

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[criticalelement]

I've been put in charge of finding bougies for my group. I'm new to my group and I'm big proponent of using bougies with difficult airways. Somehow my group hasn't ever had them before. I'm curious as to what brand you guys have in your groups? Just for clarification, I'm not asking about long cook exchange catheters, but the gum elastic bougies with bent tip.

Before the glidescope the bougie was the go to tool to get you out of difficulty. why doesnt your group haveone?

 

[Arch Guillotti]

why doesnt your group haveone?

Did you see the part where he said he was new?

 

[sleepallday]

I've been put in charge of finding bougies for my group. I'm new to my group and I'm big proponent of using bougies with difficult airways. Somehow my group hasn't ever had them before. I'm curious as to what brand you guys have in your groups? Just for clarification, I'm not asking about long cook exchange catheters, but the gum elastic bougies with bent tip.

sun-med.com

 

[criticalelement]

Did you see the part where he said he was new?

He is new but the groups isn't! Did you see the part where I asked him why his group didnt have one?

 

[urge]

He is new but the groups isn't! Did you see the part where I asked him why his group didnt have one?

What does that mean? I have never used one. They didn't have them in my residency (pre glidescope) and I have been just fine without them.

 

[RedAnesthesia]

Before the glidescope the bougie was the go to tool to get you out of difficulty. why doesnt your group haveone?

Our patient population is 60% peds and 40% adults which often times peds population it isn't needed. I asked the question multiples times why we don't have them and nobody really knows. Bougies have saved my ass more than I can count. We will be getting some soon depending on what I pick. Thanks for any input.
Red

 

[Ezekiel2517]

blue ones from sun med

 

[Urzuz]

http://sun-med.com/products/intubation-aids/introducers/original/introducer-bougie

 

[Planktonmd]

I never use bougies either and to date I guess I have been lucky

 

[ranvier]

One of my critical care attendings would always put a bougie in his pocket as we ran to codes. It must have been a talisman as we never used it (when I was on service )

 

[Noyac]

http://www.smiths-medical.com/produ...-stylets/tracheal-tube-introducers-and-guides

Not everyone trained with these tools. But those that know how to use them swear by them. There is rarely an airway that can't be intubated with a glidescope and a boogie. The two alone are good but together they are unbeatable with the exception of the FOB scope.

 

[chfo]

The bougie is archaic.

 

[jwk]

The bougie is archaic.

So is oxygen.

 

[RedAnesthesia]

The bougie is archaic.

Just another tool in the tool belt my friend. It's a bougie for Christ sake and it's not like I'm asking what the best lightwand out there to use.

 

[Noyac]

The bougie is archaic.

So is a BP cuff, are you saying you don't use these either?
A lines in everyone.

And the PA catheter is as well. But new fancy transtracheal Impetence CO devices haven't proved any better either.

Are we to discard any technology over 20 yrs old?

What a stupid comment. I hope you were joking.

 

[urge]

For those of you who use these things, when does it help you? Grade 4 view? Grade 3 view?

Having never used one, I don't see how it would be much different than a styletted tube, when you are simply aiming at a hole you cannot see.

 

[IceMD]

Very useful with a Grade 3 view, not so much a grade 4 view unless you get lucky. Grade 3 with a bougie seems a lot easier to me then grade 3 with a stylet, but default at my institution is "grade 3, grab the bougie" so I'm likely biased. They both seem to go in either way these days. I do notice the feel of tracheal rings much more with the bougie (and I worry a little about tracheal damage doing that with a stylet).

And I'd second the blue sum-med ones that are single use. The multi use ones seem to get floppier with age and it becomes tough to feel tracheal rings to confirm placement.

 

[Mman]

For those of you who use these things, when does it help you? Grade 4 view? Grade 3 view?

Having never used one, I don't see how it would be much different than a styletted tube, when you are simply aiming at a hole you cannot see.

because a bougie is much smaller than a tube and you can fit it through a much tougher target. You've never had a time when you could get some sort of view but couldn't pass the tube? You can always pass the bougie. If you can see any part of the glottic opening you can get the bougie through with ease almost every time.

Bougies are fantastic.

 

[urge]

One of my critical care attendings would always put a bougie in his pocket as we ran to codes. It must have been a talisman as we never used it (when I was on service )

Many of my older attendings used to carry (and still do) a Rusch stylet all the time but I have never seen anyone use it.

 

[goosegas]

The Bougie still has a relevant place in airway management. These work just as well as the Sunmed bougie but are significantly less expensive. You can get them on Medline, Amazon or direct from the manufacturer (towards the bottom).

 

[RedAnesthesia]

For those of you who use these things, when does it help you? Grade 4 view? Grade 3 view?

Having never used one, I don't see how it would be much different than a styletted tube, when you are simply aiming at a hole you cannot see.

They are incredibly useful for the grade 3 views and even grade 2 views. They particularly useful with patients with redundant tissue around glottis and enables users to find glottis opening. Once the glottis opening it found you can pass the ETT over the bougie. It is easier to manipulate the bougie with coude tip and less traumatizing then jamming styletted ETT around glottis.

Red

 

[deleted162650]

In my practice the Glidescope has essentially replaced the bougie. Both devices accomplish the same goal which is to aid in securing a more "anterior" airway. I've got a bougie pinned to every machine, but if I DL and get a marginal/no view of the glottis I just come out and ask for one of the handful of Glidescopes we've got readily available. This way I'm not poking semi-rigid objects down the trachea and then railroading an ETT over the top.

In a more "austere" environment where there isn't a VL device at the ready, a bougie remains a very useful tool to have around.

 

[Metalblade]

Glidescopes are great. However, occasionally you get a good view with the glidescope but can't maneuver the tube through the glottis to save your life. Bougies are good to have then. I also carry them to codes on the floor. They fit in your back pocket a lot easier than the glidescope.

 

[chfo]

So is a BP cuff, are you saying you don't use these either?
A lines in everyone.

And the PA catheter is as well. But new fancy transtracheal Impetence CO devices haven't proved any better either.

Are we to discard any technology over 20 yrs old?

What a stupid comment. I hope you were joking.

You seriously wrote all that after I simply stated that the bougie is archaic?

It is an old tool, circa 1970s. Before the invention of more modern tools including the glidescope.

And placement of the tube still requires railroading it down the trachea, blindly. Not very elegant.

And it is not the highest success rate tool available, because you still might have to reach for the definitive tool (glidescope) anyways when you can't get the bougie in.

I'm not saying don't use it, I'm just saying that technology has advanced to provide a more elegant solution.

Which is why his old group probably doesn't even stock bougies anymore.

Saves money by having fewer supplies inventoried.

If you can DL 90% of airways, IL 99.9% of airways, and FOB 100% of airways, why pay money to stock a tool that gives you ~97% success?

 

[Docuronium]

Glidescopes are great. However, occasionally you get a good view with the glidescope but can't maneuver the tube through the glottis to save your life. Bougies are good to have then. I also carry them to codes on the floor. They fit in your back pocket a lot easier than the glidescope.

Just this week, grade 1 view, could not get tube beyond cords. Converted to DL, 2b view, first try with bougie.

Constantly have to remind people glidescopes don't fix everything

 

[deleted547339]

If you can DL 90% of airways, IL 99.9% of airways, and FOB 100% of airways, why pay money to stock a tool that gives you ~97% success?

I'm hoping this is a rhetorical question.......

Are you really arguing that you should save money by not stocking a tool that costs pennies to make? If you can get to 97 with DL + bougie, you're only having to use IL and FOB a very small portion of the time. That's got to be a huge money saver over cleaning FOB, and either cleaning the IL or the disposable cover for your IL depending on what you have.

 

[Noyac]

All I can say is WOW!

 

[chfo]

Just this week, grade 1 view, could not get tube beyond cords. Converted to DL, 2b view, first try with bougie.

Constantly have to remind people glidescopes don't fix everything

Did you actually need the bougie to intubate with a 2b view? That should be enough for a styletted tube with DL. Even a 3 can be intubated with DL + ETT + stylet and enough hook.

I'm hoping this is a rhetorical question.......

Are you really arguing that you should save money by not stocking a tool that costs pennies to make? If you can get to 97 with DL + bougie, you're only having to use IL and FOB a very small portion of the time. That's got to be a huge money saver over cleaning FOB, and either cleaning the IL or the disposable cover for your IL depending on what you have.

It doesn't cost pennies. It is sterile-packed. Unit cost is $5-$10/each. Glidescope covers are $10-15/each. And if you get a reusable glidescope blade, then the cost is even lower, less than $5/washing.

It's not an insignificant cost to stock bougies, especially if only one person is using the product. Think about expiration dates, inventorying, keeping available in every OR and offsite location, etc.

http://journals.lww.com/anesthesia-analgesia/Fulltext/2011/08000/How_Old_Is_Your__Bougie__.44.aspx
"During a recent difficult tracheal intubation, a plastic tracheal tube introducer—“bougie”4 15F 70-cm coude tip lot no. 04-2999 (SunMed, Largo, FL) broke while the tracheal tube was being introduced over it into the trachea, requiring retrieval of the broken tip from the esophagus."

http://images.journals.lww.com/anesthesia-analgesia/Original.00000539-201108000-00044.FF1.jpeg

I am merely addressing the OP's concern about not having the product at his group.

If everyone is using the product often, then there's no issue.

If only one person is using it, and rarely at that, then the cost and safety could be an issue.

 

[Wiscoblue]

I've been using a bougie for twenty plus years. I don't use a stylet. I've never used the gly-duh-scope for the several years that they have been available in our ORs. I find that my younger partners are much more likely to use the video scope. Different strokes, I guess! Maybe I'm getting all the easy airways.

 

[urge]

Just this week, grade 1 view, could not get tube beyond cords.

That's because you are advancing the Glidescope too far. Grade 2 view is what you want.

 

[Docuronium]

That's because you are advancing the Glidescope too far. Grade 2 view is what you want.

If anything the cords still felt distant. The issue with glidescope is visualizing very anterior airways then trying to manipulate an ETT in that same plane. I understand your point, and even if it had been withdrawn I doubt there would have been success. Bougie was done in ten seconds

 

[chfo]

If anything the cords still felt distant. The issue with glidescope is visualizing very anterior airways then trying to manipulate an ETT in that same plane. I understand your point, and even if it had been withdrawn I doubt there would have been success. Bougie was done in ten seconds

Sounds like the blade was too small.

The strength of glidescope is in the most anterior of airways, but the blade sizing can be tricky to achieve the best view. Did you use reusable or disposable blades? Which size?

Urge is right too, it could have been too deep.

 

[GasEmDee]

I love the gum elastic bougie.

1. It is cheap and can be placed in every room.
2. Glidescope is expensive, and so we only have several on hand, and they are kept in the anesthesia work room.
3. It works well for many grade 3 views.
4. It also works extremely well for grade 1 and 2 views were the angle of approach towards the glottis is sharp, and its hard to get a larger tube in.
5. It's cheap.
6. It's cheap.

 

[deleted547339]

Did you actually need the bougie to intubate with a 2b view? That should be enough for a styletted tube with DL. Even a 3 can be intubated with DL + ETT + stylet and enough hook.



It doesn't cost pennies. It is sterile-packed. Unit cost is $5-$10/each. Glidescope covers are $10-15/each. And if you get a reusable glidescope blade, then the cost is even lower, less than $5/washing.

It's not an insignificant cost to stock bougies, especially if only one person is using the product. Think about expiration dates, inventorying, keeping available in every OR and offsite location, etc.

http://journals.lww.com/anesthesia-analgesia/Fulltext/2011/08000/How_Old_Is_Your__Bougie__.44.aspx
"During a recent difficult tracheal intubation, a plastic tracheal tube introducer—“bougie”4 15F 70-cm coude tip lot no. 04-2999 (SunMed, Largo, FL) broke while the tracheal tube was being introduced over it into the trachea, requiring retrieval of the broken tip from the esophagus."

http://images.journals.lww.com/anesthesia-analgesia/Original.00000539-201108000-00044.FF1.jpeg

I am merely addressing the OP's concern about not having the product at his group.

If everyone is using the product often, then there's no issue.

If only one person is using it, and rarely at that, then the cost and safety could be an issue.

Dude. It's a couple bucks. If you're putting someone to sleep, a $5 tool that can help get an airway is a great investment. It's a couple bucks. So there was one bad batch of bougies- there are times when the power cord on the VL will go out and eventually one of the disposable covers for a glide scope will malfunction and break, too.

For all of the absurb, expensive medicines we give and procedures we perform in medicine that have questionable benefit at best, you're not going to convince me an airway adjunct for pennies isn't a wise investment.

 

[RedAnesthesia]

Thanks everybody for your input on choice bougies. You are going to be hard pressed to change my mind that bougies aren't a valuable intubation aid. Additionally, I find it funny how chfo brings up a claim of bougie breaking in esophagus when the glidescope itself probably has the most malpractice claims among airway injuries!

 

[VisionaryTics]

Junior ENT resident. I've used a bougie twice in the last few months on call, and I think both times it probably saved a life. Once I used it as an airway exchange catheter to get a cuffed ETT in place of an uncuffed trach tube in a patient who was having massive blood loss and aspiration from a bleeding tumor that was fungating out of the trach stoma. Once I used it to cannulate a deep, deviated tracheotomy after an unintubatable patient dislodged their trach tube.

Thing costs a couple of bucks, probably doesn't expire, and you can tape it to the side of your anesthesia cart or whatever.

 

[OB1🤙]

1) I haven't used a bougie in years, but
2) I think every OR should have a bougie available.

 

[Mman]

1) I haven't used a bougie in years, but
2) I think every OR should have a bougie available.

I use one about once a week with a CRNA that has a view but can't get the tube to pass. I grab the bougie, hand it to them, and the tube is in. Way faster than tracking down a glidescope and way cheaper than needing a glidescope in every single OR.

Every hospital should have both.

 

[Noyac]

I love it when people come here, make a ridiculous statement, get handed all kinds of information and still stick to their guns out of pride.

In the words of Chris Carter, COME ON MAN!!!!!

Btw, I know of a case where a FOB tip broke off in an airway. It was a disaster. But nobody is saying we should get rid of the FOB.

 

[codeb1ue]

I also came from a residency program that never carried bougies but rather multiple McGraths available for anyone to grab and go. I'm now in fellowship where everyone here uses a bougie and I feel like a complete idiot trying to figure it out.

I hear people saying it's good for making that sharp angle in grade 3 views but it's a straight catheter that isn't that easily malleable like a stylet. I couldn't even get it into view on the glidescope screen. I just don't get it.

 

[p30doc]

I also came from a residency program that never carried bougies but rather multiple McGraths available for anyone to grab and go. I'm now in fellowship where everyone here uses a bougie and I feel like a complete idiot trying to figure it out.

I hear people saying it's good for making that sharp angle in grade 3 views but it's a straight catheter that isn't that easily malleable like a stylet. I couldn't even get it into view on the glidescope screen. I just don't get it.

I don't know what your using but our Bougies are extremely malleable. You can bend them at any angle you want at any point on the thing.

 

[deleted547339]

And lets not forget a bougie is also extremely useful if it hits the fan and you need to do a surgical airway.

 

[OB1🤙]

And lets not forget a bougie is also extremely useful if it hits the fan and you need to do a surgical airway.

Indeed, especially as the evidence now seems to indicate that a direct bougie-assisted cricothyrotomy is superior to the Seldinger technique cric.

 

[teeva]

1) I haven't used a bougie in years, but
2) I think every OR should have a bougie available.

Same experience here and that's how we're set up.

Awhile ago I was bored and was looking through our cart. I played with the blue bougie (don't remember the brand) and it cracked into pieces when flexed. I looked at the label and it had expired years ago, and apparently became brittle with age as no one had probably used one in years. So we ordered new stock to resupply.

 

[urge]

Same experience here and that's how we're set up.

Those who have it and think is great but are not using it, why not? What are you using?

 

[IlDestriero]

I love it when people come here, make a ridiculous statement, get handed all kinds of information and still stick to their guns out of pride.

In the words of Chris Carter, COME ON MAN!!!!!

Btw, I know of a case where a FOB tip broke off in an airway. It was a disaster. But nobody is saying we should get rid of the FOB.

That's half the appeal of the anesthesia forum. The only thing missing from 5 years ago is profanity, calling the supporters of the Bougie idiots, and screaming "malpractice".
We have the single use individually wrapped Bougies, they are about $10 each.
PS if your CRNAs regularly get views and can't pass the tube, that's a problem.

 

[IlDestriero]

Indeed, especially as the evidence now seems to indicate that a direct bougie-assisted cricothyrotomy is superior to the Seldinger technique cric.

Retrograde wire.

 

[IlDestriero]

I also came from a residency program that never carried bougies but rather multiple McGraths available for anyone to grab and go. I'm now in fellowship where everyone here uses a bougie and I feel like a complete idiot trying to figure it out.

I hear people saying it's good for making that sharp angle in grade 3 views but it's a straight catheter that isn't that easily malleable like a stylet. I couldn't even get it into view on the glidescope screen. I just don't get it.

I wouldn't use it with the glidescope as ours are not malleable. You can use it to help intubate these people with standard DL and a grade 3 view though. I used them in residency, bit haven't needed one in years because of my patient population. We have them taped to the OB anesthesia machines though since I joined.
We also have a Glide there, but one can grab the Bougie and have the tube in before the tech/nurse rolls the glide over and turns it on, let alone placing a cover on the probe, etc.

 

[Mman]

PS if your CRNAs regularly get views and can't pass the tube, that's a problem.

For those that are math impaired, once a week equals about 1-2% incidence.