Use of the Bougie Endotracheal Tube Introducer in Unstable Cervical Spine Airway Management?

Abstract

To the Editor Holmes et al1 provide a succinct, up-to-date account of airway management techniques in patients with an unstable cervical spine at a busy trauma center. Their results are notable for high first-attempt success rates with both video laryngoscopy (VL) and smaller cohorts of awake fiberoptic bronchoscopy–guided intubation or a combined hybrid technique. Success rates were lower with an asleep fiberoptic bronchoscopy technique and a very small group with traditional direct laryngoscopy. We have increasingly incorporated use of the bougie endotracheal tube introducer in patients undergoing VL or direct laryngoscopy with a cervical collar in place and concern or risk for cervical spine instability. Advantages for increased first-pass success and decreased neck motion have been well described.2,3 One of the authors is currently training flight nurses and emergency paramedic colleagues with a VL-guided + bougie technique for all prehospital intubations with very high first-pass success. Use of the bougie as an aide is not described in the current article, and we were curious whether those data were available and, if so, whether there was any detectable impact on success rates or change in use over time. First attempt on the majority of intubations was either by an anesthesiology resident or certified registered nurse anesthetist under direct faculty supervision. Because all major level 1 trauma academic training institutions balance the need for the education of junior residents, we acknowledge the need to have the most proficient intubator perform the initial attempt in patients at particularly high risk to maximize success. We also wished to know whether the authors were able to detect any signal from the experience of the resident trainee or intubator and first-pass success for the various techniques. Descriptions of current standard clinical techniques from experienced trauma centers are useful for the anesthesiology community, and we commend Holmes et al1 for their addition to the topic. Christopher T. Stephens, MDJohanna B. De Haan, MDSam D. Gumbert, MDEvan G. Pivalizza, MBChB, FFASAUTHealth McGovern Medical SchoolHouston, Texas[email protected]