Gum Elastic Bougie

[corpsmanUP]

In order to help promote scholarly thinking in a forum that has turned a bit adversarial lately, I would like to seek the opinion of my esteemed attendings and upper levels (and anyone else) here about an idea I have.

First, is everyone familliar with the "bougie" for intubating? I had never even seen one before residency and now I am finding it an invaluable tool. In fact, I like it so much that I am seriously considering a study to compare the bougie versus the routine ETT technique for first line airway, not as a backup.

Now I hear the screams coming from the gallery already so please just hear me out. In my lifetime, I have probably done less than a total of 30 intubations. Half of these I have done since starting my residency in July, and the other half were as a paramedic. One of the critical points for me in intubation has always been passing the damn tube. I'm talking about when I have a great or at least good view. For whatever reason, I have never really determined the best way to shape the tube nor have I determined how deep the stylet should go for ease of insertion. I bet on over half my intubations, I had to take the tube out, and re-shape it, or attempt to turn a good view into a great view. As we all know, one of the biggest visual obstructions when intubating with a "good" view versus a great view is the tube itself.

What I have been doing lately is to simply obtain my view, whether it is poor, good, or great, and then I insert the bougie first. Then I simply have someone pass the tube over the bougie and I then take it from them and pass it while maintaining constant direct visualization of the tube passing into the trachea. I feel it gives a much better path for the tube to follow and may even cut down on trauma to the cords. It certainly has been a time saver in my opinion because I don't have to find the stylet, insert it in the tube, shape the tube, and try one to 2 passes before I get it in. Another great thing is that I find myself able to insert the tube exactly to the point where the cuff passes the cords, whereas with the traditional stylet I have often hit an end point where I have to try and slide the tube off the stylet while advancing it to the correct position.

I know it seems like the "wuss" way of intubating, but I am finding it an incredible asset. At minimum I believe it can help those new to intubating to be able to gain their "view" confidence over many months until they can master the tube placement without it. I just think it is a great bridge tool for newcomers in the field. And I believe it could be even more important for people who do not intubate regularly, like small town ED docs and ALS units that don't run a ton of calls.

For those that don't know what a bougie is, it is a long narrow, soft, nurf-like consistency stylet-looking thing that is about 2 feet long. It is much narrower than the ET tube itself and much easier to pass into the trachea. It has a "bent-up" tip to allow you to feel when you hit cricoid rings if you simply have a terrible view. It is passed into the trachea some 4" or so (some advocate sinking it, but I get a bit nervous doing that). Then you slide the ETT over it and watch it go into th trachea, and then remove it out the end like a stylet.

I am hoping to come up with a way to prospectively study the device and determine how useful it could be in the situations I am describing. It only costs $8.00 and can be kept in your pocket even when on off-services. That is where I have seen it most useful...you know, those IM floors where the code is run very poorly and you have to step over the bed to get into the corner to try and intubate in a contorted position. And I can't even imagine the implications this device could have on prehospital EMS calls.

Let me know what you think.

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[FISKUS]

I know of several ground emt-p units that use the eschmann stylett as a standard intubating tool. There is also quite a bit of info on flightweb.com if you search the forums.

 

[The White Coat Investor]

In
I am hoping to come up with a way to prospectively study the device and determine how useful it could be in the situations I am describing. It only costs $8.00 and can be kept in your pocket even when on off-services. That is where I have seen it most useful...you know, those IM floors where the code is run very poorly and you have to step over the bed to get into the corner to try and intubate in a contorted position. And I can't even imagine the implications this device could have on prehospital EMS calls.

Let me know what you think.

Where did you buy one for $8?

 

[psychbender]

One of our EPs is trying to bring these to his ER, and I'm hoping to convince him to let us start using them in the field (he's our OMD, too). Also, I got to see one used for the first time yesterday in the OR. The CRNA had good visualization on a patient with a very small mouth, but was unable to advance the tube properly. The Anesthesiologist supervising her asked me to get the GEB, and the tube went right in once it was employed.

As for where to get one for $8:
http://www.bellmedical.com/Stylettes.htm
Scroll down to the Eschmann stylettes. The disposable ones are 10/box, $60 per box. Or, $77 ea for the reusable ones (I think we'll stick the the disposables, thanks).

 

[corpsmanUP]

One of our EPs is trying to bring these to his ER, and I'm hoping to convince him to let us start using them in the field (he's our OMD, too). Also, I got to see one used for the first time yesterday in the OR. The CRNA had good visualization on a patient with a very small mouth, but was unable to advance the tube properly. The Anesthesiologist supervising her asked me to get the GEB, and the tube went right in once it was employed.

As for where to get one for $8:
http://www.bellmedical.com/Stylettes.htm
Scroll down to the Eschmann stylettes. The disposable ones are 10/box, $60 per box. Or, $77 ea for the reusable ones (I think we'll stick the the disposables, thanks).

Yes, we use the disposable ones. We have no heartburn about opening one up and then not needing it. They are not sterile and can be kept open on the cart as long as you reseal the package. I often carry one without the package in my pocket and I would certainly use it regardless if I needed on the floor somewhere outside the ED.

 

[WilcoWorld]

At Advocate Christ we just had our annual "Difficult Airway Day". This is an entire day of conference dedicated to difficult airway management. We start off with some didactics on identifying difficult airways before they become problematic and the different tools available to help with them. Then we spend the rest of conference practicing them. Today I practiced the GEB, lighted stylet, digital intubation (no thanks), cricothyrotomy, cricothyrotome, view finder, retrograde intubation, and (my personal fav) fiberoptic intubations (oral and nasal). We even had two simulated cases (one peds, one adult) on our simman/simbaby.

We practiced these on models, of course, but it was very rewarding, and a lot of fun.

In retrospect I realize that as a 1st year I probably muscled my way through a few airways (mostly on the floor in codes) that I could've finessed with the GEB. Now I'm looking forward to using these toys (not the cric kit, obviously) as practice in some of my more straight-forward tubes.

 

[WakeMedHeel]

I think the light wand is pretty sweet and I'd love to see it used more in practice.

FWIW, the GEB is my number one back up device.

 

[12R34Y]

The Gum elastic bougie is probably hands down the best back-up airway assistance I've ever seen or heard of. I personally love it and so do many other folks I know.

It is very much used in the prehospital environment where I came from. Flightcrews use them all across the country routinely for difficult tubes.

I don't seem to have the trouble you are describing passing the tube with a stylet. So, I probably wouldn't use it first line.

One trick the anesthesiologists always due it to get your tube JUST barely past the cords and hold your tube in place and then have someone pull the stylet and pass your tube WITHOUT the stylet and it goes very easily. Just make sure the stylet is lubed well.

Have I said the bougie is AWESOME! (because it is).

later

 

[2ndyear]

I am a gas resident, I'll chime in here.
I like the idea of a study like this. But I think you'd have to define the scope of the problem, ie how many grade 1-2 views on direct laryngoscopy, have difficult tube placements. And then does the trauma of Bougie placement equate to less trauma than more than one attempt at passing the tube. I'd venture that with a good view the Bougie causes minimal to no trauma, but the tube can still hang up on the cords or the arytenoids and cause trauma. We all know that mashing the tube in and not getting it the first time leaves a bloody mess for the second attempt and therein lies your study. We use catheter over wire all the time for other things, a lines, central lines, etc. Why not intubation? On the same note, I've done a bunch of fiberoptics that have the exact same problem. Pass the scope through the cords but can't get the tube in. That can really suck. I've found that the tubes packaged in the intubating LMA kits are very soft on the end and just sort of slide in no problem. No real use once you've already got a scope passed, but not a big deal with a Bougie. Of course it's main value would be in practitioners that have little intubation experience to maximize the passing of the tube. By the end of your EM residency you won't fall into this group anymore and you'll be an airway expert.

I had the same problem you describe when I started, and I still run across it 1.5 years later. I think it's usually related to too much of a bend. A full 90 degree 'hockey stick' is too much for me unless I've got someone holding the right corner of the mouth away from my view.

 

[basementbeastie]

straight to cuff then bend 30 degrees - keeps tube out of line of sight and allows for easy passage.

 

[Seaglass]

Also bring the tube in from the right side - not head on.

 

[FISKUS]

Disposable " tube changers" aka GEB or eschmann stylett at sunmedusa.com

about $50 for a box of 10

 

[FoughtFyr]

Corpsman,

Either get Iowa to pay for you (or even suck up the cost yourself) to attend Levitan's Practical Emergency Airway Management Course (http://www.airwaycam.com/course.asp - note to mods, I have no affiliation with this course, financial or otherwise). He really breaks it down for you. On the question of how to shape the tube, keep the tube straight until the cuff, then a 30 degree bend. The sylet should be inserted until it is 0.5 - 1 cm from the end of the tube.

Now for the study. With due respect to our "gas" friends, meaningful studies of intubation techniques are extremely difficult. Mallinpati, LEMON, and just about every other "pre tube" measure (expect history of previous difficult intubation) has fallen apart in the EM literature. The problem is two-fold, first, airways are most often emergent affairs, where little in the way of "go / no go" decision making to use. So trying to identify what made a given intubation difficult is difficult. The second point, and one that Levitan hammers home, is that you should have a ~98% first pass success in intubation. With only 2/100 "misses", getting a study to statistical power is very difficult. If your success rate is lower than that, the operator proficiency would be called in question as tainting the data, as this figure is published and well accepted.

Lastly, the Bougie isn't free of it's own problems. Tubes can "hang up" on the cords or the Bougie can "fall out" during manipulation. Where I really like the Bougie is in confirming tube placement...

- H

 

[roja]

I love the bougie. Its phenomenal. We only got it during my last year of residency.

We have a study looking at exactly this. We have already submitted much of the data (on grade views, common adjustment techniques, etc) and are now in the process of analyzing data on the bougie.

 

[docB]

I love the bougie. I carry one (the expensive one in the plastic case) around with me and to all the floor codes I go to. I could gush about them but I'd be repeating previous posts.

I would be wary about using it as a first pass device. The majority of tubes go in without a backup device. FF mentioned some of the possible complications of the bougie. I believe I've heard of trach tears and perfs with stylets as well.

Having said that I applaud your thinking. Without a study we don't really know if it's better worse or the same. As Roja mentioned there are people out there already studying these. I know Aaron Bair at UC Davis has done lots of work on this. Don't let that totally discourage you though. The idea of using it for a first pass device could also be studied in each environment, EMS, aero, etc.

 

[Seaglass]

IIRC there are already a lot of studies on the bougie and it is definitely my go-to #2 approach but I'm down with what Foughtfyr is saying - you chould be able to get it in 1 attempt >90% of the time so if you're having that much trouble initially you just need more practice. It gets easier and easier the more you do it.

 

[corpsmanUP]

We have thought about randomizing the study into two groups whereas perhaps one day of the week is bougie day, and the other traditional day. What I want to show is that whether or not you have a grade 1 view or not, that first line bougie may be more time effective and user-friendly than ETT placement with stylet.

At least half the tubes I have already done in the department have been the type where we had no way to adequately prepare because the patient simply "went bad" or was brought in "worse" than anticipated. In those instances, you have 2 choices as I see it.

First choice: If you are the airway person, you will be suctioning, bagging, dropping an oral airway or trumpet while the person behind you is getting your tube and equipment. We don't keep a tube in the airway cart that already has a lubricated stylet in it, so you have to 1) get your tube, 2)get the stylet, 3)rely on someone else (often an NA) to insert it the way you want and lubricate it the way you want, and then hand it to you, whereas you will 4)shape it the way you want, wipe all the unnecessary lube off the tube and your hands because excess goo makes it tough to hold the tube and manipulate it in fine ways.

or...

Second choice: If you are the airway person, you will be suctioning, bagging, dropping an oral airway or trumpet while the person behind you is getting your tube and equipment Then 1) ask for the size tube you want, and a bougie, and even with a great view, pass the bougie and immediately pass the tube over it. I have tried it both ways and I firmly believe that the bougie technique saves time and effort.

The funny thing about the study that I am just now getting off the ground is that I am not intending to look at the data obtained by difficult airways. I actually am not a huge proponent of the bougie when you can't see cords, because a couple of times in this situation, accompanied by the glide scope, I could literally see the tube getting hung up as it made the bend even with the bougie in place.

My premise is that using the bougie first line should be a normal part of daily ED life, when and if you have a good view. I am not interested at this point in proving the bougie's worth in difficult airways.

If anyone out there would like to consider conducting a branch of this study at their own facility, then PM me and we can talk more.

 

[corpsmanUP]

Thanks guys for the tip on the shaping of the tube. I have seen people do this but I thought it was simply crazy! I have always been taught to follow the "hockey stick" shape with a slight "J" shape. I will start trying the recommended shape and see if it makes a difference.

 

[Seaglass]

Sounds like you have a somewhat complicated setup for the tube. For example here at the Baptist I may have to start bagging the patient but in a minute or two respiratory will be there and I can set up my own tube and scope, etc. For routine use I don't lubricate the stylet and I don't have any trouble with it. I'm sure this varies with brand of stylet used.