Bougie: do you use it or not?

[urge]

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Jet likes it. I have never used it. What are your thoughts on it?

 

[jetproppilot]

Jet likes it. I have never used it. What are your thoughts on it?

I USE IT.

Funny, though.

I emerged from residency not even knowing of it's existence.

NOW, THOUGH, I KNOW if you see ANY part of the HOLY GRAIL'S APERTURE,

NO MATTER HOW SMALL, YOU'RE LOOKING AT A TARGET YOU KNOW YOU CAN'T HIT WITHHA TUBE, BUT YOU MIGHT HIT IT WITH A STRAW,

BINGO.

"BOUGIE, PLEASE."

Seriously,

the BOUGIE has nearly eliminated fiberoptic intubation from my practice.

Since in 99.9997865345% of cases we can insert a Bougie.

NO DOUBT has changed my anesthetic practice.

Almost no need for fiberoptic.

 

[huktonfonix]

i love the thing. But its no better or worse than any plan B or C. Some people have the light wand. others have the FBO, others the intubating LMA. I like the bougie because its so easy to have on hand and you dont need to rely on visualization for it to be successful which comes in handy in semi-blind attempts or lots of blood in the airway.

 

[Bertelman]

Seen it used successfully a few times, without all the hurrah of the emergency cart, etc.

 

[proman]

I use it, but don't really like it. It took me a week of using it electively on every DL before I got the hang of manipulating it. Still have never felt the clicking of the rings.

 

[isoman2000]

The best easiest cheapest assist for a difficult airway ever, I mean ever invented, love it, love it, love it.

 

[jetproppilot]

I use it, but don't really like it. It took me a week of using it electively on every DL before I got the hang of manipulating it. Still have never felt the clicking of the rings.

Its not intended as an AUDITORY ADJUNCT, Dude.

Please don't use it blind like some SUPERMAN.

There are many airways that you can see the bottom of the arytenoids....you can see where you need to go....

and yet you can't navigate a tube there.

BUT, AHA!

You CAN navigate a BOUGIE there.....you can navigate a Bougie many times where no tube has gone before.

I use it VISUALLY.... to place a conduit to what I'm LOOKING AT but can't place a tube into.

 

[Noyac]

I have used it on a few occasions. It works great. I never used it in residency though. Not sure why. Don't even remember having it available then.

It can make you look special.

 

[huktonfonix]

I agree its not auditory, but it is partially TACTILE. I will also use it in situations where there is that epiglottis only view since the glottic opening has got to be there somewhere. Now Im not gonna bluntly ram it in, but if it slides easily somewhere and I happen to feel that click-click-click it makes me feel all happy inside and saves me the trouble of breaking out the FBO

 

[jetproppilot]

I have used it on a few occasions. It works great. I never used it in residency though. Not sure why. Don't even remember having it available then.

It can make you look special.

Me either.

 

[urge]

OK, my hunch was right. I don't think I'll benefit from the bougie then.

 

[jetproppilot]

I agree its not auditory, but it is partially TACTILE. I will also use it in situations where there is that epiglottis only view since the glottic opening has got to be there somewhere. Now Im not gonna bluntly ram it in, but if it slides easily somewhere and I happen to feel that click-click-click it makes me feel all happy inside and saves me the trouble of breaking out the FBO

WOW.

I put that success rate at about FIFTEEN PERCENT.

SO WHAT WOULD BE THE POINT SPREAD ON YOU GETTING A SUCCESSFUL INTUBATION WITH THE CLICK-CLICK-CLICK????

I'M TAKING THE MINUS NINE SPREAD ON THE "CLICK-CLICK-CLICK TECHNIQUE."

 

[huktonfonix]

point spread is poor, but might as well try it while the techs are getting plan C (FBO, glide scope, whatever) ready since Ive got the laryngoscope in and some sorta view anyway. In other words low risk, potential benefit.

 

[usnavdoc]

I like a regular tube exchanger a bit better as they are stiffer, easier to manipulate and feel the rings more. Although, I do use the bougie some as well.

 

[SleepIsGood]

WOW.

I put that success rate at about FIFTEEN PERCENT.

SO WHAT WOULD BE THE POINT SPREAD ON YOU GETTING A SUCCESSFUL INTUBATION WITH THE CLICK-CLICK-CLICK????

I'M TAKING THE MINUS NINE SPREAD ON THE "CLICK-CLICK-CLICK TECHNIQUE."


(point being, Dude, in case you missed it, that, uhhhhhhhh, using the CLICK CLICK technique is not applicable, pragmatically, to a private practice setting.)

We have the bougie...lots of the 'older' attendings use it, as such we have a few by each anesthesia machine.

But how are you using it? DL with left hand, see what you can, then insert said bougie? Now bougie is in...atleast you think. Do you then remove laryngoscope (or do you have someone else holding the scope)? Say you removed the laryngoscope, are you just blinding threading a tube clockwise to ~22cm? Check for fog, BS, Capno?

 

[periopdoc]

I LOVE the bougie. When I am on airway call, I always have one coiled up in my back pocket. It is the most portable plan B that I know of. I also use it in the OR when I get the grade three view and I can't quite get the tube to make the bend.

I will run it along the epiglottis until a slight bit of resistance is felt. Back off 1 mm and direct the tip ever so slightly posteriorly then advance. I can usually feel the tracheal cartilage, but I also recognize the difference in resistance between the esophagus and the trachea.

Once I am happy with my bougie placement, I have an assistant thread the ETT over the bougie and grab the free end of the bougie. With the laryngoscope still engaged, I thread the ETT into the trachea under partial direct visualization. Sometimes I can see the tube resting between the cords afterwards, sometimes not.

I have never attempted a bougie with a grade four view but it might be a useful adjunct to digital intubation.

-pod

 

[urge]

I LOVE the bougie. When I am on airway call, I always have one coiled up in my back pocket. It is the most portable plan B that I know of. I also use it in the OR when I get the grade three view and I can't quite get the tube to make the bend.

I will run it along the epiglottis until a slight bit of resistance is felt. Back off 1 mm and direct the tip ever so slightly posteriorly then advance. I can usually feel the tracheal cartilage, but I also recognize the difference in resistance between the esophagus and the trachea.

Once I am happy with my bougie placement, I have an assistant thread the ETT over the bougie and grab the free end of the bougie. With the laryngoscope still engaged, I thread the ETT into the trachea under partial direct visualization. Sometimes I can see the tube resting between the cords afterwards, sometimes not.

I have never attempted a bougie with a grade four view but it might be a useful adjunct to digital intubation.

-pod

Dude, you sound like a bougie expert and you are only a resident. This speaks volumes to me. For you to have seen so many patients where you could only intubate with a bougie only means that you are doing something wrong at laryngoscopy. An unanticipated difficult airway is really rare. I only remember 4 and 2 of them had tongue cancer and coded.

 

[usnavdoc]

Dude, you sound like a bougie expert and you are only a resident. This speaks volumes to me. For you to have seen so many patients where you could only intubate with a bougie only means that you are doing something wrong at laryngoscopy. An unanticipated difficult airway is really rare. I only remember 4 and 2 of them had tongue cancer and coded.

Im guessing he is talking about codes(poor positioning and no time to mess around with making things optimal) especially with the new ACLS guidelines where they dont halt chest compression for intubation. Thats where I have used bougies and exchangers the most. Although it is rare that I have to pull it out of my pocket to use it regardless of the situation.

 

[Trisomy13]

Dude, you sound like a bougie expert and you are only a resident. This speaks volumes to me. For you to have seen so many patients where you could only intubate with a bougie only means that you are doing something wrong at laryngoscopy. An unanticipated difficult airway is really rare. I only remember 4 and 2 of them had tongue cancer and coded.

or practicing a lot with the bougie so it's natural in a true emergent situation... just another perspective. i've used the bougie several times, starting early CA-1, but usually on normal grade 1-2 views just to get the hang of it. haven't needed it in a code situation yet (knock on wood) but i have at least used it enough to know i can use it quickly and with a degree of confidence if the need arises.

 

[periopdoc]

Dude, you sound like a bougie expert and you are only a resident. This speaks volumes to me. For you to have seen so many patients where you could only intubate with a bougie only means that you are doing something wrong at laryngoscopy. An unanticipated difficult airway is really rare. I only remember 4 and 2 of them had tongue cancer and coded.

Where did I make mention of an UNANTICIPATED difficult airway? I have had one of those. It was in my second month of residency.

There have been 2-3 times when I had an anticipated difficult airway in the OR, got the grade three view and used a bougie in the manner described.

I have resorted to it once on the floor during a code situation.

My comfort in using the bougie comes from training. I will take a patient with a normal appearing airway. Induce, DL for the expected view, then I relax that to a grade 3 view and use the bougie as I described before. What does it feel like in the esophagus? What does it feel like in the trachea?

I do the same thing with elective FOB's, intubating LMA's, glidescopes and digital intubations. I do it so often that I piss off our anesthesia techs because they have to turn over all of the equipment that I go through. THAT is what residency is about, taking full advantage of the situation you are in, and taking full advantage of the expertise of your attendings to give you pointers on improving your technique.

If you save plan B for an emergency situation, and only use it in that situation, it is next to worthless. It has to be second nature. You have to constantly practice plan B and C and D so that you have the confidence to switch to them, and the skills to successfully implement them when you do switch.

If I sound like a bougie expert it is because I am a bougie expert. I do not compromise on laryngoscopy skills or on backup devices. I AM an expert in airway management because ultimately, when the **** hits the fan, I have to be the airway management expert. My surgical colleagues expect that of me, my patients expect that of me, my anesthesia colleagues expect that of me, and they damn well better expect it of themselves because I expect it of them when I call for their help BEFORE I institute plan B.



-pod


And I suppose I am obliged to say something about the volumes it speaks to me about the judgement of someone who has had not only one but two unanticipated difficult airways in patients with TONGUE CANCER.

 

[deleted59964]

hi all

i've seen bougies used many times with success and without fuss by attendings. i've used it once under supervision as a med student, for a grade 3 view - worked beautifully.

....

i've also seen 1 death in an icu patient who was recovering from a heart transplant, and needed re tubing in a hurry - difficuly airway, inexperienced intubator attempted bougie (which back then was sharp so you could feel the tracheal rings better) --> tension pneumothorax --> EMD --> RIP😱

i think bougies are softer and more rounded now though?

 

[Arch Guillotti]

I love the bougie. I always kept one in my residency during nights on call as well. I have used it enough to become comfortable with it. To assume someone has poor airway skills just because they are very familiar w/a rescue device is pretty dumb. I used it many times to practice during a normal DL, worsening my view to a grade 3 on purpose. Also used it in emergent situations such as codes on the floor or RSI's in folks w/c-collars. Ideally you should keep your view while as an assistant threads the ET tube while you watch, but you can thread it blindly by yourself if need be.

I agree w/JPP that it is a poor device for godawful grade 4 views. It is best for those situations when you can catch only a glimpse of the appropriate structures. Honestly, I have only felt the click-click of the rings a few times but when you do feel it you know you are in the right spot without even checking anything else.

My favorite trick on call when I got a potentially challenging airway on an ICU gomer in the middle of the night was to use the bougie as a stylette. Regardless, when I went on these calls and I had no one else to help me w/real airway experience I would always tuck the bougie under the head of the bed just in case.

 

[urge]

To assume someone has poor airway skills just because they are very familiar w/a rescue device is pretty dumb. I used it many times to practice during a normal DL, worsening my view to a grade 3 on purpose.

Practice! What's the learning curve of placing a stick in a hole? People need practice for that? WTF!

Are you doing an OB fellowship too?

 

[ucsfgaspain]

Bougie groupie here too. Quick, easy...don't feel for clicks...just ram it in..spin the tube counterclockwise if it gets hung up on the aretynoid. Keeps the drama low so I can jump back on the iphone and watch all my stocks tank.

I "practice" all the time. I see it like golf. Even though, I can nail my 7 iron. I still take occasional practice swings just to keep the skillz finely honed.

 

[pgg]

Practice! What's the learning curve of placing a stick in a hole? People need practice for that? WTF!

🙄 Consider the possibility that there may be some subtleties (such as the tactaile sensation of tracheal rings) that may require some repetitions to fully appreciate, and that the moment you're executing plan B might not be the best time to learn them.

It's all just putting a stick in a hole. Why practice with any adjunct?

 

[MTGas2B]

Practice! What's the learning curve of placing a stick in a hole? People need practice for that? WTF!

Are you doing an OB fellowship too?

Its the learning curve of the subtleties, using a little curve in the bougie, feeling for rings, not pushing it too deep, and most importantly knowing when to ask for it without missing a beat, so you're not using it in a flail, and keep things smooth. I've seen what happens when novice bougie users decide they need it. Not smooth.

Its a great tool.

 

[SleepIsGood]

Fellas-

any of you concerned about perforating the trachea?

An attending of mine told me tht with those "Cook" caths used for exchanging tubes, there's a concern hitting the carina with it, causing a cough,etc and perforating the trach. Even if they dont cough, perforating the trach.

I just don't see how this can be. No one is going to "shove" a Cook Cath into the trachea, or atleast they shouldnt. Similarly, isnt a bougie even more sturdy than a Cook Cath? So let's say when you are essentially 'blindly' threading the bougie where you think the cords are, but it goes deeper.

Any of you guys heard/seen perf'd trachs d/t this reason? I just can't imagine why it is a concern if using 'gentle' insertion.

 

[Trisomy13]

Practice! What's the learning curve of placing a stick in a hole? People need practice for that? WTF!

Are you doing an OB fellowship too?

Well, you claim to have never used it. Try it and then tell us about the learning curve.

Jeez.

 

[psychbender]

Practice! What's the learning curve of placing a stick in a hole? People need practice for that? WTF!

So there's no learning curve with ET intubation (which is also "placing a stick in a hole")?

I've only used a bougie a few times in the ED, and once in the OR. I asked for the bougie a second time in the OR, the attending thought I just wasn't doing it right...then asked for the bougie herself. I felt some small amount of vindication at that.

Additionally, I've been trying to get the bougie adopted by the EMS agency I run with, as I think it would be a great adjunct in the prehospital setting. This is especially true for when providers may not get even one intubation per year, and need all the help that they can get.

 

[urge]

So there's no learning curve with ET intubation (which is also "placing a stick in a hole")?

The learning curve is exposing the cords. Not pushing the tube down.

Either you see them or you don't. If you see them, then you don't need the bougie. If you don't, then you are sticking blindly which you can do with the ET tube. There is no skill involved in the latter.

 

[Jeff05]

can anyone recommend a particular brand and website where to buy.

i have an old one that one of my attendings got on a trip to germany, but i've been looking for a new one.

 

[militarymd]

Where did I make mention of an UNANTICIPATED difficult airway? I have had one of those. It was in my second month of residency.

There have been 2-3 times when I had an anticipated difficult airway in the OR, got the grade three view and used a bougie in the manner described.

I have resorted to it once on the floor during a code situation.

My comfort in using the bougie comes from training. I will take a patient with a normal appearing airway. Induce, DL for the expected view, then I relax that to a grade 3 view and use the bougie as I described before. What does it feel like in the esophagus? What does it feel like in the trachea?

I do the same thing with elective FOB's, intubating LMA's, glidescopes and digital intubations. I do it so often that I piss off our anesthesia techs because they have to turn over all of the equipment that I go through. THAT is what residency is about, taking full advantage of the situation you are in, and taking full advantage of the expertise of your attendings to give you pointers on improving your technique.

If you save plan B for an emergency situation, and only use it in that situation, it is next to worthless. It has to be second nature. You have to constantly practice plan B and C and D so that you have the confidence to switch to them, and the skills to successfully implement them when you do switch.

If I sound like a bougie expert it is because I am a bougie expert. I do not compromise on laryngoscopy skills or on backup devices. I AM an expert in airway management because ultimately, when the **** hits the fan, I have to be the airway management expert. My surgical colleagues expect that of me, my patients expect that of me, my anesthesia colleagues expect that of me, and they damn well better expect it of themselves because I expect it of them when I call for their help BEFORE I institute plan B.



-pod


And I suppose I am obliged to say something about the volumes it speaks to me about the judgement of someone who has had not only one but two unanticipated difficult airways in patients with TONGUE CANCER.

DAMN...3 WHOLE years of experience...and all that BRAVADO....I hate to see what you'll be like in 10 more years.

 

[militarymd]

Fellas-

any of you concerned about perforating the trachea?

An attending of mine told me tht with those "Cook" caths used for exchanging tubes, there's a concern hitting the carina with it, causing a cough,etc and perforating the trach. Even if they dont cough, perforating the trach.

I just don't see how this can be. No one is going to "shove" a Cook Cath into the trachea, or atleast they shouldnt. Similarly, isnt a bougie even more sturdy than a Cook Cath? So let's say when you are essentially 'blindly' threading the bougie where you think the cords are, but it goes deeper.

Any of you guys heard/seen perf'd trachs d/t this reason? I just can't imagine why it is a concern if using 'gentle' insertion.

seen it ...haven't done it...yet.

 

[Bertelman]

Fellas-

any of you concerned about perforating the trachea?

An attending of mine told me tht with those "Cook" caths used for exchanging tubes, there's a concern hitting the carina with it, causing a cough,etc and perforating the trach. Even if they dont cough, perforating the trach.

I just don't see how this can be. No one is going to "shove" a Cook Cath into the trachea, or atleast they shouldnt. Similarly, isnt a bougie even more sturdy than a Cook Cath? So let's say when you are essentially 'blindly' threading the bougie where you think the cords are, but it goes deeper.

Any of you guys heard/seen perf'd trachs d/t this reason? I just can't imagine why it is a concern if using 'gentle' insertion.

I think the difference between a Cook and the bougie is the tip. The Cook has a lumen, thus the end may have more of an "edge" to catch soft tissue and tear.

The bougie is dull and rounded at the tip, thus probably more likely to bounce off into a bronchus

 

[Bertelman]

The learning curve is exposing the cords. Not pushing the tube down.

Either you see them or you don't. If you see them, then you don't need the bougie. If you don't, then you are sticking blindly which you can do with the ET tube. There is no skill involved in the latter.

I disagree. For me, there was a learning curve for both. There were several times as a med student that I had good (enough) cord exposure, but my tube wouldn't go through. Must have been hitting the cords. Sometimes the cords weren't fully abducted, and I had to learn to ease the tube through and spread the cords. I would imagine in that situation, a smaller caliber tube is easier to pass. Obviously, now I'm getting better views, thus it's easier to pass through the anterior part of the cords, but it still takes some manipulation to guide the tube down the proper trajectory through the mouth.

 

[jetproppilot]

I disagree. For me, there was a learning curve for both. There were several times as a med student that I had good (enough) cord exposure, but my tube wouldn't go through. Must have been hitting the cords. Sometimes the cords weren't fully abducted, and I had to learn to ease the tube through and spread the cords. I would imagine in that situation, a smaller caliber tube is easier to pass. Obviously, now I'm getting better views, thus it's easier to pass through the anterior part of the cords, but it still takes some manipulation to guide the tube down the proper trajectory through the mouth.

I agree with Bert's disagreement.

Sometimes a partial view (i.e. lower part of the cords) is all thats obtainable...enough to pass a Bougie but not enough to pass the tube.

Many times this is not due to poor laryngoscopy technique but rather intrinsic to the patient's anatomy.

 

[Noyac]

I agree with Bert's disagreement.

Sometimes a partial view (i.e. lower part of the cords) is all thats obtainable...enough to pass a Bougie but not enough to pass the tube.

Many times this is not due to poor laryngoscopy technique but rather intrinsic to the patient's anatomy.

Thats usually all that I see anyway.

 

[Arch Guillotti]

Sometimes a partial view (i.e. lower part of the cords) is all thats obtainable...enough to pass a Bougie but not enough to pass the tube.

WTF? Either you see them or you don't🙄

 

[urge]

I have made it my business to intubate every arythenoid I see. And, even if I only see epiglotis, I might push the tube in. It might not go on the first try, but usually does on the second or third. What you guys are doing with the bougie, I'm doing with the tube. You can say "well, what's the difference?" Not much really. But I don't depend on an extra piece of equipment. You probably run by 10 or 20 of these in a good year. I bet they are at leat $30. If there is no outcome difference, at leat I'm $300 or $600 more cost effective than you. I only ask for you to give yourself a chance and lay off the bougie.

I bet a lot of you bougie users have a hard time placing double lumen tubes too. You might use a bougie, place a single lumen, then a tube exchanger, and then finally the dlt. Well, that's a waste of time and resources. There has never been a dlt that I haven't been able to place directly. I'm a cardiothoracic anesthesiologist, BTW.

 

[jetproppilot]

I have made it my business to intubate every arythenoid I see. And, even if I only see epiglotis, I might push the tube in. It might not go on the first try, but usually does on the second or third. What you guys are doing with the bougie, I'm doing with the tube. You can say "well, what's the difference?" Not much really. But I don't depend on an extra piece of equipment. You probably run by 10 or 20 of this in a good year. I bet they are at leat $30. If there is no outcome difference, at leat I'm $300 or $600 more cost effective than you. I only ask for you to give yourself a chance and lay off the bougie.

I bet a lot of you boigie users have a hard time placing double lumen tubes too. You might use a bougie, place a single lumen, then a tube exchanger, and then finally the dlt. Well, that's a waste of time and resources. There has never been a dlt that I haven't been able to place directly. I'm a cardiothoracic anesthesiologist, BTW.

Uhhh, Urge and Arch,

HAHAHAHAHAHAHAHAHAHAHA

Guess I've missed the boat on laryngoscopy!!!😆

Coming back to REALITY though for the casual reader here, most of the regular contributors here are deft at laryngoscopy.

Despite that deftness there arises, sometimes, an inability to place the endotracheal tube despite a partial view of the larynx.

I'm a proponent of the Bougie here, as opposed to 1)repositioning and taking another look 2)resorting to other airway-securing methods.

Urge, uhhhh, Dude, thats some feisty stuff you posted that theres never been a DLT you couldnt place.

1)I'm good at this biz.
2)I'm commonly the GO TO guy for difficult laryngoscopy.
3)I work in a 21 room OR that does 70-100 cases a day.
4)I previously worked in a practice that did over 400 hearts a year.
5)I've placed....I dunno....three million double lumen tubes.🙂lol🙂
6)I've definitely had my share of DLTs that were difficult and required the interventions you described.
7)Speaking from a viewpoint of a laryngoscopist that has gravid fire ant capability, your post depicts you as ONE OF TWO THINGS:

You are either

1)JESUS CHRIST

or, more realistically, you

2)HAVENT DONE ENOUGH DOUBLE LUMEN TUBE CASES.

There are definitely DLTs that require extra effort to place them, independent of laryngoscopist prowess.

 

[urge]

HAVENT DONE ENOUGH DOUBLE LUMEN TUBE CASES.

1- I don't have as much experience as you. So, it is definitely a possibility.
2- I probably jinxed myself now.

Bougie please...😳

 

[jetproppilot]

I have made it my business to intubate every arythenoid I see. And, even if I only see epiglotis, I might push the tube in. It might not go on the first try, but usually does on the second or third. What you guys are doing with the bougie, I'm doing with the tube. You can say "well, what's the difference?" Not much really. But I don't depend on an extra piece of equipment. You probably run by 10 or 20 of these in a good year. I bet they are at leat $30. If there is no outcome difference, at leat I'm $300 or $600 more cost effective than you. I only ask for you to give yourself a chance and lay off the bougie.

I bet a lot of you bougie users have a hard time placing double lumen tubes too. You might use a bougie, place a single lumen, then a tube exchanger, and then finally the dlt. Well, that's a waste of time and resources. There has never been a dlt that I haven't been able to place directly. I'm a cardiothoracic anesthesiologist, BTW.

Read the highlighted print.

I don't push a tube unless I'm looking at a target.

You and I have different philosophies on tube placement.

You could potentially eliminate the second and third tries by using the Bougie.

A successful Bougie on first attempt is better than a tube on the 2nd or 3rd attempt, Dude.

 

[Noyac]

I have made it my business to intubate every arythenoid I see. And, even if I only see epiglotis, I might push the tube in. It might not go on the first try, but usually does on the second or third. What you guys are doing with the bougie, I'm doing with the tube. You can say "well, what's the difference?" Not much really. But I don't depend on an extra piece of equipment. You probably run by 10 or 20 of these in a good year. I bet they are at leat $30. If there is no outcome difference, at leat I'm $300 or $600 more cost effective than you. I only ask for you to give yourself a chance and lay off the bougie.

I bet a lot of you bougie users have a hard time placing double lumen tubes too. You might use a bougie, place a single lumen, then a tube exchanger, and then finally the dlt. Well, that's a waste of time and resources. There has never been a dlt that I haven't been able to place directly. I'm a cardiothoracic anesthesiologist, BTW.

WOW
Thats some bold BS.

BTW, We have reusable bougies so I don't think the cost is an issue.

 

[periopdoc]

... even if I only see epiglottis, I might push the tube in. It might not go on the first try, but usually does on the second or third. What you guys are doing with the bougie, I'm doing with the tube...

You probably run by 10 or 20 of these in a good year. I bet they are at least $30. If there is no outcome difference, at leat I'm $300 or $600 more cost effective than you...

I bet a lot of you bougie users have a hard time placing double lumen tubes too. You might use a bougie, place a single lumen, then a tube exchanger, and then finally the dlt.

I assume when you say second or third attempt you mean 2-3 passes with the ETT during a single laryngoscopy not 2-3 attempts of hooking up and attempting ventilation.

In fact, like you, I frequently do the exact same thing with a styletted ETT that I do with a bougie. It doesn't have quite the same feel and there can be some difficulty getting the tube to smoothly make the bend, but I completely agree that sometimes you can use this technique without the bougie.

However, I would argue that their are still some airways that are easier to efficiently intubate with the bougie. When I come across one of those airways, I will likely recognize it, grab my bougie, and have the patient intubated a couple of minutes faster than if I didn't have it. How much is a minute of OR time running these days? If I can save 5-10 minutes a year, perhaps I have been more cost effective than you.

The bougie I use is reusable, although it probably isn't hugely cheaper than a disposable if you count the cost of personnel to sterilize and restock them etc. As a resident, I am conscious of cost containment, but keep it secondary to my goal of having as much training as possible. While I plan to change my priorities when I am in practice, I will not balk at spending a few hundred dollars a year to keep up my skills. That is hella cheaper than a CME course or a lawsuit for failed airway management. The latest airway skills seminar that I received a flyer for was $1195 plus travel plus lodging plus...

I have never had a problem placing a DLT, but my n is quite low. I am on CT again next month and I probably just jinxed myself. Since I can't "electively" place DLTs for routine cases it is harder to build up a reasonable n but I have never resorted to the technique you describe. If I needed to, I would probably skip the first two steps and place the tube exchanger instead of the bougie.


-pod


btw Thanks for bringing up so many interesting cases. This afternoon I read through several old threads that you started as case discussions. 👍 Keep them coming.


_________________

 

[dA pilot]

Fellas-

Any of you guys heard/seen perf'd trachs d/t this reason? I just can't imagine why it is a concern if using 'gentle' insertion.

At my former gig, there were 2 cases of bronchial tears resulting in pneumos due to in the heat of the moment passing the bougie too deep. There is sometimes a black line across some bougies that indicate mid trachea position.

 

[urge]

An acquaintance of mine perforated the trachea with a DLT. Didn't take the stylette out and pushed hard. Immediate sub q pneumo and hypoxia ensued.

 

[Arch Guillotti]

I bet a lot of you bougie users have a hard time placing double lumen tubes too. You might use a bougie, place a single lumen, then a tube exchanger, and then finally the dlt. Well, that's a waste of time and resources. There has never been a dlt that I haven't been able to place directly. I'm a cardiothoracic anesthesiologist, BTW.

🙄🙄🙄

See JPP's reply.

 

[geauxg8rs]

Bougie tip:
Instead of folding it up and getting it all bent up in your back pocket. I would thread it in the drawstring of my scrub pants. It gets a lot less bent. It also doesn't get launched out of my back pocket when I go to sit my fat butt down. Thus keeping the third part of the abc's of anesthesia intact(Airway, Book, Chair).😀

 

[ssmallz]

Saw this on a stat page last. We go up the unit, guy has throat cancer and opens his mouth about half an inch. D/L, can't see anything, use the mcgrath, can kinda see cords but can't pass tube. Bougie in the mouth and through the cords, ett over and in. Definatly a slick move and made me a firm believer int he bougie.

 

[Gimlet]

Bougie tip:
Instead of folding it up and getting it all bent up in your back pocket. I would thread it in the drawstring of my scrub pants. It gets a lot less bent. It also doesn't get launched out of my back pocket when I go to sit my fat butt down. Thus keeping the third part of the abc's of anesthesia intact(Airway, Book, Chair).😀

I bet that looks sweet when you draw it out of your scrubs like a sword. En garde!