Rigid bougies?

[thegenius]

I helped assist in a difficult intubation the other day. A pt undergoing CPR and a colleague doing CPR and trying to tube and couldn't get it. on the glide scope all of his soft tissues were markedly edematous and I couldn't make out any landmarks at all. So i asked for a bougie and that piece of schit thing was so floppy it was useless! It was like trying to direct a wet noddle into his glottis. Ended up repositioning the patient and doing some other things and I got it with the rigid hyperangulated stylet. everything was so swollen.

It just got me thinking...the bougie we had was f'ing useless. We need a much more rigid "C" shaped bougie...or one that can be more easily manipulated into any shape...and it keeps that shape. Do those exist?

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[gruemd]

Was it one of those garbage all-plastic bougies or was it a true gum elastic bougie? I prefer the latter but it seems everywhere is moving towards the former (because $$$)

 

[Rekt]

Same thing happened to me recently. Was at anew shop doing a difficult airway and asked for a bougie and got handed some piece of crap flaccid plastic. Like I was trying to feed the patient spaghetti. They said that’s what they always use and use it to change out ETTs. I wouldn’t even have felt comfortable using it for that. I’m used to the very rigid light blue plastic with the hook hockey stick end.

 

[GassYous]

Same thing happened to me recently. Was at anew shop doing a difficult airway and asked for a bougie and got handed some piece of crap flaccid plastic. Like I was trying to feed the patient spaghetti. They said that’s what they always use and use it to change out ETTs. I wouldn’t even have felt comfortable using it for that. I’m used to the very rigid light blue plastic with the hook hockey stick end.

That's a tube exchanger. You use it to seldinger a tube out and in. It's not very good.

 

[GonnaBeADoc2222]

I helped assist in a difficult intubation the other day. A pt undergoing CPR and a colleague doing CPR and trying to tube and couldn't get it. on the glide scope all of his soft tissues were markedly edematous and I couldn't make out any landmarks at all. So i asked for a bougie and that piece of schit thing was so floppy it was useless! It was like trying to direct a wet noddle into his glottis. Ended up repositioning the patient and doing some other things and I got it with the rigid hyperangulated stylet. everything was so swollen.

It just got me thinking...the bougie we had was f'ing useless. We need a much more rigid "C" shaped bougie...or one that can be more easily manipulated into any shape...and it keeps that shape. Do those exist?

Serious question...why are you trying to intubate during CPR? Just bag or drop an LMA, no?

 

[JacobMcCandles]

Unless they can’t be bagged or it’s an upper airway issue then I’m not intubating during CPR. Was everything all edematous from the colleague mucking around in the airway?

 

[jwk]

I helped assist in a difficult intubation the other day. A pt undergoing CPR and a colleague doing CPR and trying to tube and couldn't get it. on the glide scope all of his soft tissues were markedly edematous and I couldn't make out any landmarks at all. So i asked for a bougie and that piece of schit thing was so floppy it was useless! It was like trying to direct a wet noddle into his glottis. Ended up repositioning the patient and doing some other things and I got it with the rigid hyperangulated stylet. everything was so swollen.

It just got me thinking...the bougie we had was f'ing useless. We need a much more rigid "C" shaped bougie...or one that can be more easily manipulated into any shape...and it keeps that shape. Do those exist?

The original GlideScope stylets are VERY rigid. Regular old intubating stylets are pretty rigid too. Do you not have those available?

 

[Siggy]

Tube exchangers tend to be more floppy and safer to use.

The documentation for the Medline bougies actually recommend against using them for tube exchanges because they're more rigid.

In general, bougies are meant for direct laryngoscopy and aren't designed for hyperangulated intubation.

There was a booth at SCCM's Congress this year showcasing a steerable hyperangulated bougie.

https://ttcmed.com/wp-content/uploads/2023/07/RSI-ValPack-71923-1.pdf

 

[BoardingDoc]

Tube exchangers tend to be more floppy and safer to use.

The documentation for the Medline bougies actually recommend against using them for tube exchanges because they're more rigid.

In general, bougies are meant for direct laryngoscopy and aren't designed for hyperangulated intubation.

There was a booth at SCCM's Congress this year showcasing a steerable hyperangulated bougie.

https://ttcmed.com/wp-content/uploads/2023/07/RSI-ValPack-71923-1.pdf

1: The gizmo seems interesting

2: Their statistics seem to be completely made up as far as I can tell. The link you posted shows 2 diagrams. One implies that there are 120k deaths which are due to failed intubations. Another image further down and the following text states that there are over 25k American deaths each year due to failed intubation. They then provide links to multiple sources. That still seemed high to me and so I searched every one of those sources and cannot see where they derived that information from. It is entirely possible that I missed it, but this seems like they probably found some rate of complications, inferred a death rate from that, and then inferred that a failed airway = a high mortality complication.

Of note, the top referenced source: "Schilling AL. Estimating the Economic and Absolute Number of Complications Associated with Emergency Intubations PerformedOutside the Operating Room ; A Methodology for Estimating the Burden in the US.; 2019." does not even appear to be from a journal of any kind based on the citation, and no matter how I search for this document, I can't find it anywhere online, other than on other marketing materials published by this company.

TL;DR: these people seem to be using questionable source material at best and are outright making s*** up at worst.

 

[thegenius]

Tube exchangers tend to be more floppy and safer to use.

The documentation for the Medline bougies actually recommend against using them for tube exchanges because they're more rigid.

In general, bougies are meant for direct laryngoscopy and aren't designed for hyperangulated intubation.

There was a booth at SCCM's Congress this year showcasing a steerable hyperangulated bougie.

https://ttcmed.com/wp-content/uploads/2023/07/RSI-ValPack-71923-1.pdf

Yea I kind of figured that out in real time. I even called for lots of blankets and other stuff so I could put the guy in a better "sniffing" position. Problem was we were doing CPR.
He was really fat too

He looked like this:

I ended up just raising the head of bed to 30-45 degrees during CPR and was able to tube

 

[thegenius]

The original GlideScope stylets are VERY rigid. Regular old intubating stylets are pretty rigid too. Do you not have those available?

You are right they are 100% rigid. I'm beginning to forget the details. Given that one or two other ER docs couldn't get it with a glidescope, I think the first thing I tried was passing a bougie without success (using glidescope).

 

[thegenius]

Unless they can’t be bagged or it’s an upper airway issue then I’m not intubating during CPR. Was everything all edematous from the colleague mucking around in the airway?

I don't know

 

[thegenius]

Serious question...why are you trying to intubate during CPR? Just bag or drop an LMA, no?

No I hear ya. I was called in like 30-40 minutes into CPR. I didn't know anything about what was going on, besides that there was a fat 60 yr guy getting CPR. They asked me to help intubate so I helped.

Once I learned that he had about 40 minutes of CPR...I said "do we really need to do this" and there was some mumbling and other stuff so I just proceeded

 

[xaelia]

Once I learned that he had about 40 minutes of CPR...I said "do we really need to do this" and there was some mumbling and other stuff so I just proceeded

Yeh, not much you can do when the care is being provided under the direction of another team – unless it's clearly inappropriate/dangerous etc.

I get some mileage out of kinking the bougie for better steering control, but I would no longer rate myself an expert given the paucity of intubations coming my way. Otherwise agree with above that somehow you likely were inadvertently given a tube exchanger, which would be pretty damn worthless.

 

[WorkNoteEmergency]

The light blue rigid one is my go-to. I always have one within reach for a intubation. I’ve done blind intubations twice using the blue bougie (This is over many years) The dirty looking gold/yellow ones I believe are the gum elastic ones and useless to me.

 

[Siggy]

TL;DR: these people seem to be using questionable source material at best and are outright making s*** up at worst.

To be honest, I don't care much about the studies. Talking to the guy at SCCM, I agreed that every time I've had issues with video it wasn't due to visualization, but being able to drive the catheter to the cords. Being able to adjust the bougie helps with that.

 

[EMhawkeye]

Yeh, not much you can do when the care is being provided under the direction of another team – unless it's clearly inappropriate/dangerous etc.

I get some mileage out of kinking the bougie for better steering control, but I would no longer rate myself an expert given the paucity of intubations coming my way. Otherwise agree with above that somehow you likely were inadvertently given a tube exchanger, which would be pretty damn worthless.

Look up the kiwi grip for even better steering control

 

[thegenius]

This is what was used:

I was playing with it again and I would bend it and it wouldn't really hold it's shape at all.

 

[Groove]

No I hear ya. I was called in like 30-40 minutes into CPR. I didn't know anything about what was going on, besides that there was a fat 60 yr guy getting CPR. They asked me to help intubate so I helped.

Once I learned that he had about 40 minutes of CPR...I said "do we really need to do this" and there was some mumbling and other stuff so I just proceeded

I think that's just lame to call in another doc that far into a code as an airway Hail Mary. I get it if he's 10 mins in and they are having airway issues, I've bailed out colleagues in similar conditions but 40 mins?! Does he just want to be able to document that he couldn't get an airway and made sure to ask someone else? I hope to God he didn't put your name in that chart.

 

[Groove]

These are the ones we use:

InterGuide tracheal tube introducer bougie

Intersurgical’s InterGuide is a single use, latex free, flexible tracheal tube introducer commonly known as a bougie. It allows positive location of the trachea and subsequent placement of the endotracheal tube in difficult airway situations.

www.intersurgical.com

 

[Kryptocoin]

Yea I kind of figured that out in real time. I even called for lots of blankets and other stuff so I could put the guy in a better "sniffing" position. Problem was we were doing CPR.
He was really fat too

He looked like this:

I ended up just raising the head of bed to 30-45 degrees during CPR and was able to tube

That's what my average pt looks like.

 

[Siggy]

I think that's just lame to call in another doc that far into a code as an airway Hail Mary. I get it if he's 10 mins in and they are having airway issues, I've bailed out colleagues in similar conditions but 40 mins?! Does he just want to be able to document that he couldn't get an airway and made sure to ask someone else? I hope to God he didn't put your name in that chart.

I got called once 60 minutes into a code that EMS brought to the ED.

I 100% billed for the intubation, but my procedure note starts off with, "The resuscitation effort had been ongoing for 60 minutes by the time I was called. I responded immediately [and did things]."

 

[TooMuchResearch]

I helped assist in a difficult intubation the other day. A pt undergoing CPR and a colleague doing CPR and trying to tube and couldn't get it. on the glide scope all of his soft tissues were markedly edematous and I couldn't make out any landmarks at all. So i asked for a bougie and that piece of schit thing was so floppy it was useless! It was like trying to direct a wet noddle into his glottis. Ended up repositioning the patient and doing some other things and I got it with the rigid hyperangulated stylet. everything was so swollen.

It just got me thinking...the bougie we had was f'ing useless. We need a much more rigid "C" shaped bougie...or one that can be more easily manipulated into any shape...and it keeps that shape. Do those exist?

A trick I learned in residency is to curl the bougie up and put it in some ice water for a while.

I don't know how long that takes to work though.

 

[Angry Birds]

A trick I learned in residency is to curl the bougie up and put it in some ice water for a while.

I don't know how long that takes to work though.

Then just wait 30-45 minutes before applying bougie to your emergency difficult airway.

 

[EMhawkeye]

I’ve used the new fancy one for hyperangilated blades. Wasn’t the best.
I love the new disposable fiberoptic for glidescope. Used it for a delayed rsi. Awesome.

 

[TooMuchResearch]

Then just wait 30-45 minutes before applying bougie to your emergency difficult airway.

Exactly. I do coil the thing up in a ball sometimes to get it to hook upwards even more but if that's the concern then I would potentially just switch over to a hyper angulated blade or disposable bronchoscope.

 

[ShockIndex]

We need to stop using the word GlideScope like it is a thing. GlideScope is a manufacturer. They produce an array of video airway products including standard geometry blades and hyperangulated blades, and each has a specific name. For example, their Mac and Miller products correspond to blade geometries that are remarkably similar to DL blades of the same name while the LoPro line is their hyperangulated blades.

The techniques for using the various GlideScope blades are vastly different between the geometries as is the ease of view and tube delivery to the glottis. Moreover, all conventional bougies will generally not work with any hyperangulated blade from just about any brand - GlideScope or Storz.

So, when somebody says that they struggled with a GlideScope and a bougie, my first question is what was the blade geometry since I’ve seen experienced physicians try to use a bougie inappropriately with a hyperangulated blade. Along, the same lines, our airway notes should mention the specific blade geometry (ie VL Mac 4) rather than just Glidescope, and we should mention the CL grade of view achieved with that view. It is very help for me to know that you got a grade 2b with a VL LoPro S4 if I have to reintubated someone 5 days later.

 

[Apollyon]

It's like saying all vodka is Tito's. It's not!

 

[TooMuchResearch]

We need to stop using the word GlideScope like it is a thing. GlideScope is a manufacturer. They produce an array of video airway products including standard geometry blades and hyperangulated blades, and each has a specific name. For example, their Mac and Miller products correspond to blade geometries that are remarkably similar to DL blades of the same name while the LoPro line is their hyperangulated blades.

The techniques for using the various GlideScope blades are vastly different between the geometries as is the ease of view and tube delivery to the glottis. Moreover, all conventional bougies will generally not work with any hyperangulated blade from just about any brand - GlideScope or Storz.

So, when somebody says that they struggled with a GlideScope and a bougie, my first question is what was the blade geometry since I’ve seen experienced physicians try to use a bougie inappropriately with a hyperangulated blade. Along, the same lines, our airway notes should mention the specific blade geometry (ie VL Mac 4) rather than just Glidescope, and we should mention the ML grade of view achieved with that view. It is very help for me to know that you got a grade 2b with a VL LoPro S4 if I have to reintubated someone 5 days later.

For whatever reason, people commonly say GlideScope instead of hyper angulated.
I'm a simple man and 95% of the time in adults my answer is MAC 4 with whatever video system you have available.

 

[Siggy]

For whatever reason, people commonly say GlideScope instead of hyper angulated.
I'm a simple man and 95% of the time in adults my answer is MAC 4 with whatever video system you have available.

Do you say "band aid" or "self adhesive bandage"?

 

[RustedFox]

I say "Tylenol" and not "acetaminophen".

But ShockIndex has a good point. It agitates me when people use "iPhone" to refer to any modern mobile telephone with smartphone capabilities.

Also, Apple devices suck.

 

[ShockIndex]

For whatever reason, people commonly say GlideScope instead of hyper angulated.
I'm a simple man and 95% of the time in adults my answer is MAC 4 with whatever video system you have available.

I think that its carry over from the origional GlideScope back in the early 2000s was exclusively hyperangulated.

What you do is perfect by saying, “Hand me the VL Mack 4.” Your team knows exactly what you want and can plan a backup if you struggle.

A good rule of thumb based current evidence is that most people are well served starting with a VL Mack blade for their first attempt. This allows seamless transition to a bougie for 2nd, and hyperangulated for 3rd. After that, I drop an iGel and call for additional resources while the front of the neck is prepped just in case. Usually the patient can be at least oxygenated with the iGel, and often bronchoscopically intubated through the iGel. The only people that I start with a hyperangulated are people known to have >2a view with standard geometry blades, cervical immobility, etc.

There is a trial in the ether that will compare angle geometries for 1st attempt success but it’s not yet funded.

 

[TooMuchResearch]

Do you say "band aid" or "self adhesive bandage"?

Do you say football or American Hand Egg?

 

[TooMuchResearch]

I think that its carry over from the origional GlideScope back in the early 2000s was exclusively hyperangulated.

What you do is perfect by saying, “Hand me the VL Mack 4.” Your team knows exactly what you want and can plan a backup if you struggle.

A good rule of thumb based current evidence is that most people are well served starting with a VL Mack blade for their first attempt. This allows seamless transition to a bougie for 2nd, and hyperangulated for 3rd. After that, I drop an iGel and call for additional resources while the front of the neck is prepped just in case. Usually the patient can be at least oxygenated with the iGel, and often bronchoscopically intubated through the iGel. The only people that I start with a hyperangulated are people known to have >2a view with standard geometry blades, cervical immobility, etc.

There is a trial in the ether that will compare angle geometries for 1st attempt success but it’s not yet funded.

Except I usually set it up myself because inevitably if I ask for specific supplies I will find that what I get instead is opposite of what I want or worse MAC geometry blade with the rigid hyper angulated stylet in the tube or no stylet but someone has opted to bathe the entire tube in lube and not attach a syringe. Also no one else seems to be able to find PEEP valves except for the doctor who can't leave the room and ffs when did we change supraglottic airways again? At some point we replaced the iGels with air-Q intubating LMAs. You get the idea.

 

[Siggy]

Do you say football or American Hand Egg?

I’m not the one with my underpants in a bunch about a genericized term.

Also calling “American football” just “football” in the United States of America seems more reasonable than getting upset that people say “bandaid” instead of “self adhesive bandage”… or using “Glidescope” as a generic term when everyone knows the meaning regardless of the actual system used.



Also, when I ask for a BVM or bag valve mask, no one knows what I’m talking about… because it’s an ambu bag. Same concept.

 

[Arch Guillotti]

I helped assist in a difficult intubation the other day. A pt undergoing CPR and a colleague doing CPR and trying to tube and couldn't get it. on the glide scope all of his soft tissues were markedly edematous and I couldn't make out any landmarks at all. So i asked for a bougie and that piece of schit thing was so floppy it was useless! It was like trying to direct a wet noddle into his glottis. Ended up repositioning the patient and doing some other things and I got it with the rigid hyperangulated stylet. everything was so swollen.

It just got me thinking...the bougie we had was f'ing useless. We need a much more rigid "C" shaped bougie...or one that can be more easily manipulated into any shape...and it keeps that shape. Do those exist?

yes

"Normal" bougie a lot of times aren't all that helpful with challenging video laryngoscopy because they "flop" around. Malleable ones overcome this limitation.

 

[GassYous]

We need to stop using the word GlideScope like it is a thing. GlideScope is a manufacturer. They produce an array of video airway products including standard geometry blades and hyperangulated blades, and each has a specific name. For example, their Mac and Miller products correspond to blade geometries that are remarkably similar to DL blades of the same name while the LoPro line is their hyperangulated blades.

The techniques for using the various GlideScope blades are vastly different between the geometries as is the ease of view and tube delivery to the glottis. Moreover, all conventional bougies will generally not work with any hyperangulated blade from just about any brand - GlideScope or Storz.

So, when somebody says that they struggled with a GlideScope and a bougie, my first question is what was the blade geometry since I’ve seen experienced physicians try to use a bougie inappropriately with a hyperangulated blade. Along, the same lines, our airway notes should mention the specific blade geometry (ie VL Mac 4) rather than just Glidescope, and we should mention the ML grade of view achieved with that view. It is very help for me to know that you got a grade 2b with a VL LoPro S4 if I have to reintubated someone 5 days later.

Just google it. Give the patient a kleenex, some chapstick and a hot thermos while you take an escalator up to xerox their forms. No popsicles. Just make sure the paperwork gets shredded rather than put in a dumpster.

 

[RustedFox]

Just google it. Give the patient a kleenex, some chapstick and a hot thermos while you take an escalator up to xerox their forms. No popsicles. Just make sure the paperwork gets shredded rather than put in a dumpster.

Is *dumpster* seriously a brand-name?
(I knew "Shredder" was).

 

[Siggy]

Is *dumpster* seriously a brand-name?
(I knew "Shredder" was).

"Dumpster, believe it or not, used to be trademarked term that dates back to 1936 when the Dempster Brothers developed a system of loading garbage containers onto garbage trucks. They called it a Dumpster as way to blend the name of the company and the front-end loading device for dumping garbage."

27 Trademarked Names That Have Become Commonly Used Terms

Trademark names become a part of everyday vernacular, to the chagrin of those who own the trademark. Learn some product names that are or were trademarked.

www.familyhandyman.com

::

 

[DocEspana]

Tube exchangers tend to be more floppy and safer to use.

The documentation for the Medline bougies actually recommend against using them for tube exchanges because they're more rigid.

In general, bougies are meant for direct laryngoscopy and aren't designed for hyperangulated intubation.

There was a booth at SCCM's Congress this year showcasing a steerable hyperangulated bougie.

https://ttcmed.com/wp-content/uploads/2023/07/RSI-ValPack-71923-1.pdf

I want one just as a medical fidget toy

 

[DocEspana]

This is what was used:

View attachment 382247

View attachment 382248

I was playing with it again and I would bend it and it wouldn't really hold it's shape at all.

didnt know there were other models besides this.

 

[DocEspana]

I say "Tylenol" and not "acetaminophen".

But ShockIndex has a good point. It agitates me when people use "iPhone" to refer to any modern mobile telephone with smartphone capabilities.

Also, Apple devices suck.

My personal bugaboo is BiPAP. Which is not only not what the device is called, but its not even the name of any device (at least not initially) and is only technically the name of a feature of some devices of a single producer. Its a trademark filed by Phillips for it's respironics line of BPAP/CPAP device which featured a patented "BiPAP mode" which was argued to be much better and effective than other device's BPAP mode, but it was all just marketing and it is in no appreciable way different. And somehow we all just collectively decided to stop calling the machines BPAP sometime in the early 2000s because BiPAP sounded better.

Nowadays Phillips Respironics feature BiPAP proudly on the name, but that was - like most things - a marketing decision after the fact and was not initially a part of it. Similarly, other brands cannot use the word BiPAP anywhere otherwise Phillips will find them and sue them into dust. Yet every article everywhere will talk about BiPAP and very few will acknowledge its actually a trademarked term and not actually the device (or mode) name that we are all slightly misusing.

 

[Angry Birds]

What you do is perfect by saying, “Hand me the VL Mack 4.”
.

After that you spend a couple minutes explaining to them what that is. They say, “Oh, the glideoscope?” And you say, “Yeah, the glideoscope.”