Gum Elastic Bougie Research Articles

An Algorithm for Difficult Airway Management, Modified for Modern Optical Devices (Airtraq Laryngoscope; LMA CTrach ™)

Because algorithms for difficult airway management, including the use of new optical tracheal intubation devices, require prospective evaluation in routine practice, we prospectively assessed an algorithm for difficult airway management that included two new airway devices. After 6 months of instruction, training, and clinical testing, 15 senior anesthesiologists were asked to use an established algorithm for difficult airway management in anesthetized and paralyzed patients. Abdominal, gynecologic, and thyroid surgery patients were enrolled. Emergency, obstetric, and patients considered at risk of aspiration were excluded. If tracheal intubation using a Macintosh laryngoscope was impossible, the Airtraq laryngoscope (VYGON, Ecouen, France) was recommended as a first step and the LMA CTrach™ (SEBAC, Pantin, France) as a second. A gum elastic bougie was advocated to facilitate tracheal access with the Macintosh and Airtraq laryngoscopes. If ventilation with a facemask was impossible, the LMA CTrach™ was to be used, followed, if necessary, by transtracheal oxygenation. Patient characteristics, adherence to the algorithm, efficacy, and early complications were recorded. Overall, 12,225 patients were included during 2 yr. Intubation was achieved using the Macintosh laryngoscope in 98% cases. In the remainder of the cases (236), a gum elastic bougie was used with the Macintosh laryngoscope in 207 (84%). The Airtraq laryngoscope success rate was 97% (27 of 28). The LMA CTrach™ allowed rescue ventilation (n = 2) and visually directed tracheal intubation (n = 3). In one patient, ventilation by facemask was impossible, and the LMA CTrach™ was used successfully. Tracheal intubation can be achieved successfully in a large cohort of patients with a new management algorithm incorporating the use of gum elastic bougie, Airtraq, and LMA CTrach™ devices.

The use of the left-molar approach for direct laryngoscopy combined with a gum-elastic bougie

Department of Anesthesiology and Intensive Care Medicine, Ankara Training and Research Hospital, Ankara, Turkey Correspondence to Ozgun Cuvas, MD, Specialist, Department of Anesthesiology and Intensive Care Medicine, Ankara Training and Research Hospital, Ulucanlar, Ankara 06340, Turkey Tel: +90 312 595 31 84; fax: +90 312 363 33 96; e-mail: [email protected] Received 7 March 2010 Accepted 7 May 2010

A two-bougie technique for safer oro- to nasotracheal tube exchange in a difficult airway

There is a considerable risk of loss of airway control during an oro- to nasotracheal tube exchange in a patient with a difficult airway. Various techniques have been described to negotiate this potentially life-threatening situation safely [1–3]. We describe a simple and effective two-bougie technique, which facilitated a safe oro- to nasotracheal tube exchange, in a patient with a known difficult airway. A 56-year-old, 90-kg man with hepatic cirrhosis required emergency tracheal intubation and ventilatory support for acute respiratory distress. Orotracheal intubation was difficult, necessitating two attempts and the use of a stylet. We assessed his laryngoscopy as Cormack and Lehane grade 3 and inserted an 8.5-mm cuffed tracheal tube. Subsequently, the patient required endoscopic oesophageal variceal ligation, so we were requested to re-intubate the trachea nasally, to facilitate the procedure. With the orotracheal tube in situ, we introduced an 8.0-mm cuffed tracheal tube nasally into the oropharynx. We then inserted a gum-elastic bougie through the nasal tube and further advanced this bougie alongside the previously placed orotracheal tube. We then guided this bougie towards the glottis and into the trachea with the help of direct laryngoscopy, external laryngeal pressure, Magill forceps and the sensation of tracheal clicks as it slid into the trachea. We then inserted a second bougie through the orotracheal tube, into the trachea and removed the orotracheal tube after cuff deflation, leaving the oral bougie in the trachea. We then advanced the nasal tube into the trachea over the nasal bougie and confirmed its position by auscultation and capnography following the removal of the bougie. Finally, the oral bougie was also removed. The patient’s cardiovascular parameters and oxygen saturation were maintained throughout the tube exchange, which took only a few minutes. Several devices and techniques have been described for oro- to naso tracheal tube exchange, such as a tracheal tube exchanger, gum-elastic bougie and flexible fibreoptic bronchoscope [1–3]. However, these techniques have disadvantages such as a difficult technique, complex equipment and most importantly, potential for loss of airway control on removal of the oral tube. Our technique was fairly simple. While the nasal bougie facilitated nasal intubation, in the event of an unsuccessful nasal intubation or accidental dislodgement during the transition, the oral bougie served as a standby for immediate re-intubation. The bougies did not encroach significantly into the available oral workspace required for the various manoeuvres during the procedure. Ideally, we would have preferred to use an airway exchange catheter instead of a bougie through the oral tube as the continuous oxygen insufflation through the former would have added to the safety of the procedure, but we do not have these devices available in our hospital. In conclusion, a two-bougie technique can be a useful method for safer oro- to nasotracheal tube exchange, in patients with difficult airways. No external funding and no competing interests declared. Published with written assent from the patient’s next of kin (patient unfortunately deceased).

High-Risk, Low-Volume Procedures

Hill C, Reardon R, Joing S, Falvey D, Miner J. Cricothyrotomy technique using gum elastic bougie is faster than standard technique: a study of emergency medicine residents and medical students in an animal lab. Acad Emerg Med 2010;17:666-9.

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Part 8: Advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations

Difficulties with Gum Elastic Bougie Intubation in an Academic Emergency Department

Background The difficulties with gum elastic bougie (GEB) use in the emergency department (ED) have never been studied prospectively. Objectives To determine the most common difficulties associated with endotracheal intubation using a GEB in the ED. Methods We conducted a prospective, observational study of GEB practices in our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000 patients. Laryngoscopists performing a GEB-assisted intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), reason for GEB use, and problems encountered. Data were analyzed using standard statistical methods and 95% confidence intervals. Results A GEB was used for 88 patients. The overall success rate was 70/88 (79.6%; 95% confidence interval [CI] 71.1–88.0%). The GEB failure rate of the first laryngoscopist was 25/88 (28.4%; 95% CI 21.0–40.3%), with the two most common reasons being: inability to insert the bougie past the hypopharynx in 13 (52%; 95% CI 32.4–71.6%) and inability to pass the endotracheal tube over the bougie in six (24%; 95% CI 7.3–40.7). Conclusions The GEB is a helpful rescue airway device, but emergency care providers should be aware that failure rates are relatively high at a teaching institution.

Gum elastic bougie-assisted intubation following hemorrhage in the floor of the mouth

Upper airway obstruction caused by postoperative hemorrhages or surgical manipulation is one of the life-threatening complications for which oral and maxillofacial surgeons may have to initiate emergency management of the airway. Therefore, oral and maxillofacial surgeons need to be skilled in emergency airway management. However, intubation under these circumstances may be very difficult or impossible using direct visual laryngoscopy techniques. This case report describes a case of successful intubation assisted by a gum elastic bougie for an asphyxiating patient suffering from a severely compromised upper airway.

Effect of cardiopulmonary resuscitation on intubation using a Macintosh laryngoscope, the AirWay Scope, and the gum elastic bougie: A manikin study

Background Physicians could encounter difficult intubation during cardiopulmonary resuscitation (CPR) in trauma patients due to the patient's movement from continuous chest compression and to cervical stabilisation. Therefore, first, we evaluated the impact of chest compression with or without cervical stabilisation on intubation with a Macintosh laryngoscope. Next, we compared difficulty in intubation among the Macintosh laryngoscope, AirWay Scope (AWS), and gum elastic bougie (GEB) with the Macintosh laryngoscope in three simulated CPR scenarios in a randomised, controlled, cross-over study design. Methods Twenty-three anaesthetists intubated the trachea of a manikin (ALS Skill Master, Laerdal Medical Japan, Tokyo, Japan) using the Macintosh laryngoscope, AWS, and GEB in the control scenario, chest compression scenario, and chest compression with cervical stabilisation scenario. Difficulty in intubation was rated on a 5-point scale and the intubation time was measured. Results Continuous chest compression increased difficulty in intubation with the Macintosh laryngoscope, compared with the control scenario. Concurrent application of cervical stabilisation further increased the difficulty, compared with application of chest compression alone. Of the three devices compared, the AWS facilitated the easiest intubation, and the GEB facilitated the second-easiest intubation in all scenarios, though the intubation time was slightly longer with the GEB than with other devices. Conclusion CPR employing continuous chest compression with or without cervical stabilisation caused difficult intubation with the Macintosh laryngoscope. The AWS and GEB facilitated the easiest and second-easiest intubation, respectively, even during CPR employing continuous chest compression with or without cervical stabilisation in a manikin.

Cricothyrotomy Technique Using Gum Elastic Bougie Is Faster Than Standard Technique: A Study of Emergency Medicine Residents and Medical Students in an Animal Lab

The objective was to compare time to completion, failure rate, and subjective difficulty of a new cricothyrotomy technique to the standard technique. The new bougie-assisted cricothyrotomy technique (BACT) is similar to the rapid four-step technique (RFST), but a bougie and endotracheal tube are inserted rather than a Shiley tracheostomy tube. This was a randomized controlled trail conducted on domestic sheep. During a 3-month period inexperienced residents or students were randomized to perform cricothyrotomy on anesthetized sheep using either the standard technique or the BACT. Operators were trained with an educational video before the procedure. Time to successful cricothyrotomy was recorded. The resident or student was then asked to rate the difficulty of the procedure on a five-point scale from 1 (very easy) to 5 (very difficult). Twenty-one residents and students were included in the study: 11 in the standard group and 10 in the BACT group. Compared to the standard technique, the BACT was significantly faster with a median time of 67 seconds (interquartile range [IQR] = 55-82) versus 149 seconds (IQR = 111-201) for the standard technique (p = 0.002). The BACT was also rated easier to perform (median = 2, IQR = 1-3) than the standard technique (median = 3, IQR = 2-4; p = 0.04). The failure rate was 1/10 for the BACT compared to 3/11 for the standard method (p = NS). This study demonstrates that the BACT is faster than the standard technique and has a similar failure rate when performed by inexperienced providers on anesthetized sheep.

Case Scenario: Perioperative Airway Management of a Patient with Tracheal Stenosis

TRACHEAL stenosis is a rare but a life-threatening condition and is caused by congenital problems, postintubation injury, trauma, tracheal tumor, and compression of the trachea by tumor. Although accurate prevalence of this condition is unknown, an incidence of 4.9 cases per million per year is estimated for postintubation tracheal stenosis. A stenosis commonly occurs at the cuff of the tube (intrathoracic trachea) or at the level of the tracheostomy stoma (extrathoracic trachea). Anesthesia of a patient with tracheal stenosis is challenging for anesthesiologists. Depending on the severity and location of the stenosis and the type of surgical procedure, there may be a variety of choices for perioperative airway management such as a facemask, laryngeal mask airway, an tracheal intubation tube, cardiopulmonary bypass, and extracorporeal membrane oxygenation. The American Society of Anesthesiologists practice guidelines for management of the difficult airway primarily focus airway problems caused at the extrathoracic airway and may not be helpful, particularly for managing patients with intrathoracic tracheal stenosis. In this case scenario, we present a patient with severe intrathoracic tracheal stenosis, who required surgery for a lumbar fracture in the prone position. Various airway management strategies and the actual management used are discussed.

A reply

I am grateful for the interest and comments but feel that the paper and its references supply answers to most of the comments [1]. A literature search will give an indication of, for example, the efficacy and safety of direct laryngoscopy and use of the gum elastic bougie (an old technique) [2] and the complications of a comparable new technique [3-5]. Similarly, the frequency of case reports of retrograde intubations can be found even on Google. In many parts of the world the new technology, or the expertise to use it, is not available. The retrograde technique, for good reasons, is still being recommended in the developed world, even in non-anaesthetic environments [6]. I consider needle cricothyrotomy with a 13- or 14-G cannula or open cricothyrotomy more ‘invasive’ than the use of a 20-G cannula through the same space. Would a cricothyroid cannula to ventilate the lungs while performing routine fibreoptic laryngoscopy guided intubation [7] be considered invasive? To be ‘trained’ with a technique one has to train in it. When one is ready to accept a technique as a ‘last ditch’ effort (because it works), it makes sense to learn and use it in cases of anticipated difficulty under controlled conditions or to have a low threshold to use it early when confronted with unanticipated difficulty.

Comparison of bougie-guided insertion of Prosealtmlaryngeal mask airway with digital technique in adults

The Proseal™ laryngeal mask airway (PLMA™, Laryngeal Mask Company, UK) was designed to improve ventilatory characteristics and offer protection against regurgitation and gastric insufflation. The PLMA is a modified laryngeal mask airway with large ventral cuff, dorsal cuff and a drain tube. These modifications improve seal around glottis and enable better ventilatory characteristics. The drain tube prevents gastric distension and offers protection against aspiration. There were occasional problems, like failed insertion and inadequate ventilation, in placing PLMA™ using the classical digital technique. To overcome these problems, newer placement techniques like thumb insertion technique, introducer tool placement and gum elastic bougie (GEB)-aided placement were devised. We compared classical digital placement of PLMA™ with gum elastic bougie-aided technique in 60 anaesthetised adult patients (with 30 patients in each group) with respect to number of attempts to successful placement, effective airway time, airway trauma during insertion, postoperative airway morbidity and haemodynamic response to insertion. The number of attempts to successful placement, airway trauma during insertion and haemodynamic response to insertion were comparable among the two groups, while effective airway time and oropharyngeal leak pressure were significantly higher in bougie- guided insertion of PLMA. Postoperatively, sore throat was more frequent with digital technique while dysphagia was more frequent with bougie guided technique. Hence gum elastic bougie guided, laryngoscope aided insertion of PLMA is an excellent alternate to classical digital technique.

Difficult Airway Management Algorithm in Emergency Medicine: Do Not Struggle against the Patient, Just Skip to Next Step

We report a case of prehospital “cannot intubate” and “cannot ventilate” scenarios successfully managed by strictly following a difficult airway management algorithm. Five airway devices were used: the Macintosh laryngoscope, the gum elastic Eschmann bougie, the LMA Fastrach, the Melker cricothyrotomy cannula, and the flexible fiberscope. Although several airway devices were used, overall airway management duration was relatively short, at 20 min, because for each scenario, failed primary and secondary backup devices were quickly abandoned after 2 failed attempts, each attempt of no more than 2 min in duration, in favor of the tertiary rescue device. Equally, all three of these rescue devices failed, an uncuffed cricothyroidotomy cannula was inserted to restore optimal arterial oxygenation until a definitive airway was secured in the ICU using a flexible fiberscope. Our case reinforces the need to strictly follow a difficult airway management algorithm that employs a limited number of effective devices and techniques, and highlights the imperative for early activation of successive preplanned steps of the algorithm.

Application of Gum Elastic Bougie to Nasal Intubation

Gum elastic bougie (GEB), a useful device for difficult airway management, has seldom been used for nasotracheal intubation. Among 632 patients undergoing dental procedures or oral surgery, GEB was used successfully in 16 patients in whom conventional nasal intubation had failed because of anatomical problems or maldirection of the tip of the tracheal tube. We recommend that GEB should be applied from the first attempt for nasal intubation in patients with difficult airways.

Airway loss after recent tracheostomy: use of digital confirmation

Early unintentional dislodgement of a tracheostomy tube presents a potentially lethal clinical event. During the early stage, attempts to re-insert a tracheostomy tube may cause a false tract and severe surgical emphysema with external compression of the trachea and asphyxia. We have successfully re-established the airway in a patient following recent elective tracheostomy after accidental dislodgement of the tracheostomy tube. This was perfomed by inserting the index finger through the tracheostomy incision, while intubation was attempted under direct laryngoscopy. The operator passed a finger through the tracheal orifice, palpated the tracheal rings and passing the finger cephalad, confirmed digitally the passage of a gum elastic bougie into the trachea. A Portex, size 6.5 tracheal tube (Smiths Medical International, Watford, Herts, UK) was advanced over the bougie. This was a life-saving manoeuvre, as other means of establishing the airway had failed. The intubation was difficult, and all the attempts at intubation were complicated by ongoing severe surgical emphysema. Digital assisted oro-tracheal (without tracheostomy) [1, 2] or trans-tracheal intubation (through tracheostomy) [3] have been well described, particularly in children and infants. The incision on the tracheal wall in our case was a window-type, as opposed to a simple vertical incision. In case of a vertical tracheal wall incision, the trachea remains closed, therefore blind insertion of a finger is difficult, as there is no obvious gap. It is more important to try to feel for the tracheal window rather than the tracheal rings alone. The opening of the tracheal wall in the window-type incision allows the digital manoeuvre to (i) confirm the passage of a bougie, and (ii) provide a plug on the slit, so that a bougie or tracheal tube does not exit through it. Additionally, ventilation may be possible through it, and finally, if experienced staff are available, re-insertion of a tracheostomy tube is much easier. The size of the tracheal window is important. Incisions that allow insertion of tracheostomy tubes smaller than size 8.0 are small and it may be difficult to feel the gap and insert a finger. Palpation of the trachea and digital insertion should be gentle with no undue force. Sutures on either side of the tracheostomy tunnel, for approximating the skin, should be removed to facilitate finger insertion. Adequate illumination of the tracheal wound is important, as visual confirmation of the tracheal window is possible and may accelerate the procedure. The digital assistance through the tracheal slit was performed by a consultant anaesthetist, experienced in tracheostomies. Equally, in similar events, immediate assistance should be sought from surgical departments involved in tracheostomies. In our case, an otorhinolaryngologist was not immediately available. We believe that digital assistance of endotracheal intubation through tracheostoma by an experienced anaesthetist may provide a safe and rapid alternative in emergency situations. It should be considered when other ways to establish the airway fail or equipment is not immediately available.

Using a gum-elastic bougie and nasogastric tube to facilitate oral to nasal tracheal tube change in a trauma patient

Using a gum-elastic bougie and nasogastric tube to facilitate oral to nasal tracheal tube change in a trauma patient

A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: A manikin study

Background Insertion of a supraglottic airway and tracheal intubation through it may be indicated in resuscitation scenarios where conventional laryngoscopy fails. Various supraglottic devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), the Ctrach™ laryngeal mask and the I-gel supraglottic airway. Methods A prospective study with 25 participants evaluated the success rate of blind intubation (using a gum-elastic bougie, an Aintree intubating catheter (AIC) and designated tracheal tube) and fibrescope-guided tracheal intubation (through the intubating laryngeal mask airway and the I-gel supraglottic airway) on three different airway manikins. Results Twenty-five anaesthetists performed three intubations with each method on each of three manikins. The success rate of the fibrescope-guided technique was significantly higher than blind attempts ( P < 0.0001) with both devices. For fibreoptic techniques, there was no difference found between the ILMA and I-gel ( P > 0.05). All blind techniques were significantly more successful in the ILMA group compared to the I-gel ( P < 0.0001 for bougie, Aintree catheter and tracheal tube, respectively). Conclusions The results of this study show that, in manikins, fibreoptic intubation through both ILMA and I-gel is a highly successful technique. Blind intubation through the I-gel showed a low success rate and should not be attempted.

The C-MAC Videolaryngoscope: First Experiences with a New Device for Videolaryngoscopy-Guided Intubation

We studied the efficacy of the C-MAC (Karl Storz, Tuttlingen, Germany), a new portable videolaryngoscope, in 60 patients during routine induction of anesthesia. It was possible to insert the blade (Size 3) of the C-MAC and to get a view of the glottis on the first attempt in all patients. Tracheal intubation also was successful in all 60 patients; 52 patients were intubated on the first attempt, 6 on the second, and 2 on the third. In 8 patients (13%), a gum elastic bougie guide was required. A Cormack-Lehane Class 1 view of the glottis was seen in 30 patients without external manipulation and in 45 with external manipulation, Class 2a view in 22 without and 12 with, Class 2b in 2 without, and Class 3 in 2 without manipulation. The median time taken for tracheal intubation was 16 s (range, 6-58 s). In addition, we describe our experience with 3 patients in whom we had unexpected difficulty with direct laryngoscopy with a conventional Macintosh laryngoscope (Cormack-Lehane Class 3, 4, and 4, respectively). These patients' airways were successfully managed on the first attempt when using the C-MAC Size 4 blade (improvement to Cormack-Lehane Class 1, 2a, and 2b, respectively) in a modified manner by uploading the epiglottis, which is known as "straight blade technique."

Capnography and oxygenation via single-use bougie

1. Annamaneni R, Hodzovic I, Wilkes AR, Latto IP. A comparison of simulated diffi cult intubation with multiple-use and single use bougies in a manikin. Anaesthesia. 2003;58:45–9. 2. Al-Shaikh B. Capnography through the lumen of tracheal tube guide. Anaesthesia. 2003;58:809–10. 3. Sellers WFS. Finding the use for a tracheal tube guide. Anaesthesia. 2003;58:190. 4. Al-Shaikh B, Philips M. Tracheal tube introducer and capnography in diffi cult intubation. CPD Anaesthesia. 1999;1:153. 5. Miller FA, Hutchison GL, Glavin R. Gum elastic bougie, capnography and apnoeic oxygenation. Eur J Anaesthesiol. 2001;18: 51–3.

Arytenoid Subluxation after a Difficult Intubation Treated Successfully with Voice Therapy

Arytenoid subluxation is a rare laryngeal injury that may follow instrumentation of the airway and present as hoarseness, vocal fatigue, stridor, dysphagia, odynophagia and sore throat. We report the case of an 88-year-old man with type 2 diabetes mellitus who developed this complication during a difficult intubation where a Macintosh laryngoscope and gum elastic bougie were used to facilitate intubation. Previously considered to play a minor role in treatment, voice therapy was used successfully in this patient to correct subluxation of the arytenoid, with prompt resolution of his symptoms.