Bougie: do you use it or not?

[seamonkey]

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In my limited experience as med student and now intern...I have never seen a bougie used ever.Admittedly, my chances have been with ER or pulm who called gas if they don't get it, but gas has always gotten it once they hit the room. Never seen a bougie used ever. Admittedly, i'm an intern and have not even done my Er month yet.

I've done a few tubes on the floor so far (i think i have it easy with mostly edentulous pt's almost but not quite dnr/dni.). When gas makes it there , i've never heard them ask for one. Admittedly, by then I'm sent elsewhere as this is now an ICU patient and "i should spend my time elsewhere" (per program director). I guess i keep missing the good stuff. I get told to leave and deal with my bs patients.

I hate intern year. this is crap.

I bet I should be careful what i wish for, though.

 

[periopdoc]

So last night I am one of the late calls and I get the following page from charge.

"Go to OR-8 for a stat redo AAA coming in now. Dr. X attending"

Pulse is up a little bit (mine). Quick scan of online record is pretty scant. No new labs since her preop. Page the attending from the AM surgery who says case went ok except for "some airway difficulties" at the beginning of the case. Can't be more specific except to say that the CA-2 who intubated took 2-3 attempts and had difficulty.

Patient shows up and it turns out it was an endovascular repair and she has clotted off her left femoral artery. They want to do a thrombectomy. Pulse slows down a little bit (mine).

Large patient, but nothing remarkable for my institution. Review of previous anesthetic record shows DL successful on 3rd attempt with some trauma. ~6L of crystalloid resuscitation intraop. Pulse increases a little bit (mine).

Patient markedly sedated from opiates given for ischemic leg pain. Go back to OR. 75 mg propofol and patient unresponsive. Mask vent easy. SUX.

DL shows supraglottic EDEMA and clot. Can't see cords, but can see the supraglottic inlet and a dark hole behind it. OK no problem. Try to pass styleted ETT without success due to resistance of supraglottic tissue. Pulse doesn't change (mine) because I have my trusty bougie at the ready.

Grab bougie cause the dark hole is about the right size. Bougie passes easily and bingo I feel the bump bump bump of tracheal rings. Tech threads tube and I grab it while he takes control of bougie. Watch tube pass supraglottic tissue with a slight touch of corkscrewing. Gently slam it home. + EtCO2, + Chest rise, + =BBS, + normalized pulse (mine)

Could I have eventually passed it without the Seldinger-like support of the bougie? Maybe. It could just as easily have been a case of setting a vicious cycle into motion with worsening swelling making it harder to intubate and ventilate.


-pod


ps extubation was straightforward, it went well and patient has no sequelae except for minor sore throat.

 

[colchicine]

So last night I am one of the late calls and I get the following page from charge.

"Go to OR-8 for a stat redo AAA coming in now. Dr. X attending"

Pulse is up a little bit (mine). Quick scan of online record is pretty scant. No new labs since her preop. Page the attending from the AM surgery who says case went ok except for "some airway difficulties" at the beginning of the case. Can't be more specific except to say that the CA-2 who intubated took 2-3 attempts and had difficulty.

Patient shows up and it turns out it was an endovascular repair and she has clotted off her left femoral artery. They want to do a thrombectomy. Pulse slows down a little bit (mine).

Large patient, but nothing remarkable for my institution. Review of previous anesthetic record shows DL successful on 3rd attempt with some trauma. ~6L of crystalloid resuscitation intraop. Pulse increases a little bit (mine).

Patient markedly sedated from opiates given for ischemic leg pain. Go back to OR. 75 mg propofol and patient unresponsive. Mask vent easy. SUX.

DL shows supraglottic EDEMA and clot. Can't see cords, but can see the supraglottic inlet and a dark hole behind it. OK no problem. Try to pass styleted ETT without success due to resistance of supraglottic tissue. Pulse doesn't change (mine) because I have my trusty bougie at the ready.

Grab bougie cause the dark hole is about the right size. Bougie passes easily and bingo I feel the bump bump bump of tracheal rings. Tech threads tube and I grab it while he takes control of bougie. Watch tube pass supraglottic tissue with a slight touch of corkscrewing. Gently slam it home. + EtCO2, + Chest rise, + =BBS, + normalized pulse (mine)

Could I have eventually passed it without the Seldinger-like support of the bougie? Maybe. It could just as easily have been a case of setting a vicious cycle into motion with worsening swelling making it harder to intubate and ventilate.


-pod


ps extubation was straightforward, it went well and patient has no sequelae except for minor sore throat.

How about Fast track/intubating LMA vs bougie for an unanticipated difficult airway (emergency or not) where fiberoptic is not an option ?

I'd like to get an input from several people on this...

Also what about fast track vs bougie in an emergency situation in which you cannot intubate, cannot ventilate (by mask or LMA) ?

 

[huktonfonix]

Intubating LMA, FBO, glidescope, bougie, lightwand, etc... All are fine choices for a difficult airway as long as youve got some experience with it. Of course some options arent good in certain scenarios (FBO is not my first choice in a bloody airway) but for the most part they will all work in the hands of an experienced operator. I prefer the bougie to an intubating LMA if Ive already DL'd and have some landmarks available. If I cant see anything I'll probably go with an intubating LMA/lightwand/FBO/whatever.

 

[ssmallz]

How about Fast track/intubating LMA vs bougie for an unanticipated difficult airway (emergency or not) where fiberoptic is not an option ?

I'd like to get an input from several people on this...

Also what about fast track vs bougie in an emergency situation in which you cannot intubate, cannot ventilate (by mask or LMA) ?

Different strenths for the devices you are talking about. When you can see a sliver of airway w/a grade 3 view, the bougie is very nice b/c you have a target to hit and you may be able to manipulate the bougie better than an ETT. An ILMA is a blind device and one I'd use more in a situation where you can't see any airway or you know a bougie won't be able to fit.

If you can't intubate/can't ventilate, the next step should be to try an LMA or ILMA, if that don't work, cut the neck.

 

[huktonfonix]

I think the trachesostomy is an important rescue maneuver, but must be taken in context of the patient and situation rather than blindly following the algorithm. For example, is this a normal healthy patient that youve DL'd and failed to intubate and cant intubate? If you have good support and some time/preox to spare you might want to try one more maneuver (light wand, FBO, glidescope) before commiting to a trach. Also if youve used propofol/sux and you think it will wear off soon, it may also be wise to wait. You can also consider reversing any narcs/benzos youve given to try to hasten wakeup Now, you can have someone prepping the neck and opening your kit in the meantime, but keep in mind not every non intubatable/nonventilatible patient is going to buy a trach. Now knowing when to push all in with the trach....thats what we get paid for.

 

[periopdoc]

How about Fast track/intubating LMA vs bougie for an unanticipated difficult airway (emergency or not) where fiberoptic is not an option ?

I'd like to get an input from several people on this...

Also what about fast track vs bougie in an emergency situation in which you cannot intubate, cannot ventilate (by mask or LMA) ?

Different tools for different problems. If you are getting a grade 4 view with laryngoscopy, the bougie is worthless and you may want to go to a rescue device like an LMA/ iLMA. Grade 3 or better, a bougie may be a good idea.

Your question is like asking "what screwdriver should I use to work on my car today?" It depends on the screws you are working on. You may be able to get away with a small slotted screwdriver for the majority of the work. However, you may need a phillips or a torx. You may need a long handle or an angled head. It all depends on the situation that you are presented with. Furthermore, the screwdriver I select may be different than the one you select base on our personal experience. They may or may not yield the same result.

The most important thing is having a bag of tools that you are comfortable with and having a plan of attack that you are willing and able to modify based on your findings with each attempt. In my mind, I have airway plans A, B, C,and D every time I go into the OR. However, depending on the results of plan A, plans B, C, and D may get rearranged or completely tossed out the window.

We should be spending the 3 years of residency developing and honing a plan for different airway scenarios that present themselves. (and I hope that we will all continue to hone that plan throughout our careers)

The source of my earlier diatribe regarding airway skills comes from seeing individuals that are cavalier with the airway and go into the OR with nothing in mind but plan A. There are parts of anesthesia that you can be more casual with as you progress in training from the CA-1 year to the attending level and beyond, but I do not believe it is defensible to be mentally casual with the airway at any point in your career.

In the last case I presented, an intubating LMA could theoretically have been disastrous since blindly ramming a tube into already traumatized tissue could have led to more edema, bleeding, and a lost airway. The C-Trach might have been reasonable since you can watch what you are doing with the tube. However, you still may have the same problem that I had with the ETT not being able to get through the tight opening presented by all of the edema and clot.

Because I had a view, the bougie was the right tool for me. Since Urge hasn't used the bougie, it probably would not have been the right tool for him and he would have found a different way of getting the ETT in... smaller tube? Mcgills? ...

- pod