When difficulty with laryngoscopy is encountered, successful tracheal access can be indicated by the tactile feedback afforded by an advancing tracheal tube introducer ("bougie"). However, there is evidence that when providers experience psychologic and physiologic stress, their cognitive and motor abilities deteriorate. In this study, we used human cadaveric airways to examine the effect of stress on the accuracy of tactile feedback interpretation when infrequent airway providers use the bougie. This was a partially-blinded, prospective, randomized, observational study. Paramedics were recruited, underwent a brief training protocol, and were then tested during four scenarios, two of which included stressful conditions. Our primary objective was to determine whether stress significantly affected the accuracy of tactile feedback interpretation in determining tracheal vs. esophageal bougie placement in a Cormack-Lehane Grade 3a situation. Secondary outcomes included providers' confidence in their assessments, their subjective stress level, and the time taken to make a decision. Thirty-seven paramedics were randomized to complete 146 bougie assessments on cadaveric airways (74 under stressful conditions, and 72 under non-stressful conditions). Participants were significantly less accurate in determining the correct bougie location under stressful conditions, with an associated OR of 0.31 (95% CI [0.14, 0.68], p = .003). The induction of psychologic and physiologic stress significantly decreased the accuracy of interpreting tactile feedback from a bougie in cadaveric airways by prehospital providers who intubate infrequently. Our data also suggests that although participants were less accurate during the stressful scenarios, they did not report being less confident in their assessments.

IntroductionVideolaryngoscopes are recommended as the top preference for tracheal intubation in adults, children, infants and neonates, and even in patients with anticipated difficult airways, since they are generally easier to use and quicker to master than fibreoptic bronchoscopes. Compared with standard videolaryngoscopes, hyperangulated videolaryngoscopes possess a more sharply curved blade or blade tip, resulting in a higher first-attempt success rate among patients with anticipated difficult airways. However, hyperangulated videolaryngoscopes also pose challenges in advancing the tracheal tube, which decreases the first-attempt success rate while increasing the tracheal intubation time when the tracheal tube introducer is unsuitable. Hence, controversy still remains regarding the efficiency of hyperangulated videolaryngoscopes as first-line devices in patients with anticipated difficult airways, owing to the inconsistent clinical findings. Consequently, we will conduct a protocol for a systematic review and meta-analysis to determine the usefulness of hyperangulated videolaryngoscopes in patients with anticipated difficult airways.Methods and analysisEnglish-language databases (Web of Science, Cochrane Library, PubMed, Embase and Ovid Medline), Chinese electronic databases (VIP database, China National Knowledge Infrastructure, and Wanfang database) and clinical trial registry platforms will be scoured from their inception to May 2025 to locate randomised controlled trials of hyperangulated videolaryngoscopes in patients with anticipated difficult airways. For continuous data, mean differences or standardised mean differences, accompanied by their 95% CIs, and for dichotomous data, the risk ratio, accompanied by its 95% CI, will be calculated using Review Manager V.5.4. Either a fixed-effects model or a random-effects model will be used depending on the magnitude of statistical heterogeneity as evaluated via the I2 test. The risk of bias will be assessed via the Cochrane risk-of-bias tool 2. Additionally, the quality of evidence regarding each outcome will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation. The reliability of all outcomes will be appraised via trial sequential analysis. Moreover, the publication bias of all outcomes will be examined using Funnel plots and Egger’s regression test.Ethics and disseminationEthical approval was not required for this systematic review protocol. The results will be disseminated through peer-reviewed publications.PROSPERO registration numberCRD42024627484

Tracheal tube introducers facilitate tracheal intubation and include stylets and static/dynamic bougies. There is uncertainty over the most efficacious introducer with hyperangulated videolaryngoscopy. We evaluated five introducers. Thirty anaesthetists intubated a manikin 10 times with a reusable C-MAC® D-blade videolaryngoscope using five introducers in two airway setups. Airway setup was allocated randomly to standard or difficult tracheal intubation and the order of use of five introducers: two stylets (C-MAC Stylet; Universal Stylet Bougie™); two dynamic bougies (Total Control Introducer™; Steerable Tracheal Intubation Guide™); and a static bougie (Portex® Bougie). The primary outcome was first-attempt tracheal intubation success. Secondary outcomes were tracheal intubation within 120 seconds; time to tracheal intubation; and operator-rated ease of tracheal intubation, railroading and force required. With the standard tracheal intubation setup, first-attempt tracheal intubation success rates (95%CI) were: C-MAC Stylet 100% (100-100%); Universal Stylet Bougie 93% (84-100%); Total Control Introducer 90% (79-100%); Steerable Tracheal Intubation Guide 80% (65-95%); and Portex bougie 57% (37-76%). With the difficult tracheal intubation setup, first-attempt tracheal intubation success rates (95%CI) were: C-MAC Stylet 93% (84-100%); Total Control Introducer 87% (74-99%); Universal Stylet Bougie 73% (56-90%); Steerable Tracheal Intubation Guide 60% (41-79%); and Portex bougie 33% (15-51%). The C-MAC Stylet was best and the static bougie worst across all outcomes, with differences greater when tracheal intubation was designed to be difficult. In pairwise comparisons of tracheal intubation first-attempt success in the difficult airway, the C-MAC Stylet, Universal Stylet Bougie and Total Control Introducer were statistically significantly better than the Portex Bougie; the C-MAC stylet was also statistically significantly better than the Steerable Tracheal Intubation Guide. Among introducers for hyperangulated videolaryngoscopy, stylets were most efficacious and a static bougie least. Differences in performance increased when tracheal intubation was difficult.

Rapid Sequence Intubation and Use of the Bougie for Penetrating Neck Injury.

When difficulty with laryngoscopy is encountered, confirmation of endotracheal access can be confirmed using the tactile feedback (i.e., tracheal clicks) of a tracheal tube introducer (bougie). There is anecdotal evidence that a bougie placed in the esophagus may have a unique, tactile "boggy" resistance. In this study, we aimed to elucidate the sensitivity and specificity of clicks and boggy resistance for infrequent airway providers in cadaveric airways. We conducted a prospective observational study using descriptive statistics to examine the diagnostic accuracy of clicks and boggy resistance for bougies placed in cadaveric airways. We recruited prehospital providers from within Atlantic Canada who then underwent a brief formal training protocol. Cadavers were equipped with a static laryngoscope and bougie (placed either in the trachea or esophagus). Each participant, blinded to bougie placement, was then tested on two separate cadavers and asked whether they felt clicks and/or boggy resistance. Thirty-seven paramedics participated in the study (32 advanced care paramedics, five critical care paramedics) and were randomized to perform 74 bougie assessments on cadaveric airways. For tracheal clicks, we calculated an overall sensitivity of 86% (95% confidence interval [CI], 75 to 98) and an overall specificity of 81% (95% CI, 68 to 94). Sensitivity for the esophageal boggy resistance test was 78% (95% CI, 65 to 92) while specificity was 86% (95% CI, 75 to 98). Following a brief training session, prehospital providers who intubate infrequently seemed to show a relatively high degree of accuracy using tracheal clicks and esophageal boggy resistance to confirm bougie placement in cadaveric airways.

BACKGROUND Emergency airway management in trauma patients can be challenging. Injuries to the neck that cause fractures, deformities, gross hemorrhage, burns, and edema can complicate normal endotracheal intubation. This reported case is of a patient presenting with acute traumatic airway obstruction, requiring an emergency cricothyrotomy. CASE REPORT We present the case of a 51-year-old woman involved in a high-speed rollover collision presenting with altered mental status, numerous facial fractures, and large distorting anterior neck masses. Shortly after the patient's arrival at the Emergency Department, her mental status acutely deteriorated and necessitated the need for establishment of a definitive airway. Rapid sequence endotracheal intubation was attempted by the emergency and anesthesia teams using manual and video laryngoscopy techniques, but appropriate visualization of anatomical landmarks was unsuccessful. An attempt at passing an Eschmann-style bougie tracheal tube introducer was also unsuccessful, due to significant airway edema. As a last resort, an emergency cricothyrotomy was performed. During the procedure, the operator noted a distorted anatomy of the anterior neck, with a large left neck mass pushing the larynx away from the typical midline position toward the right side of the patient's neck. CONCLUSIONS This report aims to highlight the importance of airway evaluation in patients with acute trauma and has shown that cricothyrotomy is a life-saving procedure. This case report further emphasizes a need for flexibility by the trauma team to have contingencies ready for atypical presentations in which standard airway measures prove difficult to employ.

Integrating the Airway Lead structure into a large healthcare system to appraise the landscape of airway management resources

Alternative Use of the Rusch Flexi-Slip Stylet as a Tracheal Tube Introducer in an Unanticipated Difficult Airway

Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer-associated airway trauma. PubMed, EMBASE and CINAHL databases were searched using pre-determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments. We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2-31.4 [0.5-79.2])% and with bougies was 5.4% (0.4-49.9 [0.0-68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non-robust measurement of the outcome. Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma.

Background and Objective: This review summarizes the new techniques and devices available including high-flow nasal oxygen (HFNO) therapy, apnoeic oxygenation, video laryngeal mask, video laryngoscope (VL), flexible tip bougie (FTB), novel drugs, and artificial intelligence (AI) in airway management during the induction of anesthesia. Airway management during the induction of anesthesia is crucial and has progressed considerably in the past decade. Preoxygenation can improve oxygen reserves and extend the safe apnea time. Recently, preoxygenation via HFNO was introduced with significant success. The role of apneic oxygenation is also increasingly recognized. The combination of visualization and traditional intubation equipment has become the method of choice for anesthesiologists. Tracheal tube introducers are devices that can successfully aid airway management, especially in the difficult airway. The design and shape of these devices are constantly evolving to optimize intubation. Anesthetic are constantly updated to ensure the safety and efficiency. Remimazolam is a recently approved anesthetic. Remifentanil and dexmedetomidine are ideal drugs recommend in recently released Guidelines for Awake Tracheal Intubation (ATI) in Adults. The role of succinylcholine remains controversial and whether it can be replaced by rocuronium completely has triggered lots of researches. Finally, AI is a hot topic in medicine and it has been recently applied in airway management.

For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain. To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt. The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021. Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%. Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group. Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet. ClinicalTrials.gov Identifier: NCT03928925

Tracheal Tube Introducers

The passage of tube across the glottis-inlet being the significant "active" component of intubation, associating postoperative sore throat (POST) with "passive" presence of high-volume low-pressure tracheal-tube cuff is unjustified. Tracheal-tube introducers (TTI), commonly employed to facilitate tracheal intubation during difficult airway management, can influence intubation quality and decrease incidence of POST. Four hundred and fifty patients undergoing laparoscopic/open surgery were randomly allocated to receive conventional intubation (non-TTI group, N.=150) or intubation facilitated with rigid-TTI (rigid-TTI group, N.=150) or non-rigid TTI (non-rigid TTI group, N.=150). This study analyzed effects of conventional versus TTI-guided intubation on reducing the incidence of POST (primary objective); intubation profile (time, attempts, response), and complications (trauma, inspiratory stridor) (secondary objectives). Four hundred and twenty patients completed the study. The incidence of POST was lowest in patients of rigid-TTI group (N.=40, 29.0%); which was significantly lower than the non-TTI group (N.=64, 45.1%) (P=0.005) but comparable to the non-Rigid-TTI group (N.=53, 37.9%, P=0.117). In addition, the incidence of POST in rigid-TTI group was significantly lower than those in the non-TTI group at 2-hour (rigid-TTI group: N.=19, 13.8%; non-TTI group: N.=41, 28.9%, P=0.002) and 4-hour (rigid-TTI group: N.=23, 16.7%; non-TTI group: N.=43, 30.3%, P=0.007) time points. No difference was found in the incidence of airway management related morbidity, including, laryngospasm and inspiratory stridor in the three groups. Rigid-TTI by its ability to positively modify friction dynamics between glottis-inlet and the passing tracheal-tube; has the potential to improve quality of intubation and decrease the incidence of POST.

Postoperative sore throat and tracheal tube introducers.

BackgroundApplying excessive force during endotracheal intubation (ETI) is associated with several complications, including dental trauma and hemodynamic alterations. A gum-elastic bougie (GEB), a type of tracheal tube introducer, is a useful airway adjunct for patients with poor laryngoscopic views. However, how the use of a GEB affects the force applied during laryngoscopy is unclear. We compared the force applied on the oral structures during ETI performed by novices using the GEB versus an endotracheal tube + stylet.MethodsThis prospective crossover study was conducted from April 2017 to March 2019 in a public medical university in Japan. In total, 209 medical students (4th and 5th grade, mean age of 23.7 ± 2.0 years) without clinical ETI experience were recruited. The participants used either a Macintosh direct laryngoscope (DL) or C-MAC video laryngoscope (VL) in combination with a GEB or stylet to perform ETI on a high-fidelity airway management simulator. The order of the first ETI method was randomized to minimize the learning curve effect. The outcomes of interest were the maximum forces applied on the maxillary incisors and tongue during laryngoscopy. The implanted sensors in the simulator quantified these forces automatically.ResultsThe maximum force applied on the maxillary incisors was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (39.0 ± 23.3 vs. 47.4 ± 32.6 N, P < 0.001) and C-MAC VL (38.9 ± 18.6 vs. 42.0 ± 22.1 N, P < 0.001). Similarly, the force applied on the tongue was significantly lower when using a GEB than when using an endotracheal tube + stylet both with the Macintosh DL (31.9 ± 20.8 vs. 37.8 ± 22.2 N, P < 0.001) and C-MAC VL (35.2 ± 17.5 vs. 38.4 ± 17.5 N, P < 0.001).ConclusionsCompared with the use of an endotracheal tube + stylet, the use of a GEB was associated with lower maximum forces on the oral structures during both direct and indirect laryngoscopy performed by novices. Our results suggest the expanded role of a GEB beyond an airway adjunct for difficult airways.

Background and Aims:Successful intubation with video laryngoscopes necessitates good hand-eye coordination and the use of intubation adjuncts like bougie and stylet. We proposed this study to find whether using Frova introducer with C-MAC video laryngoscope will reduce the intubation time in trainee anesthesiologists.Material and Methods:We enrolled 140 adults without any difficult airway predictors. They were randomly assigned to undergo C-MAC video laryngoscope guided intubation by anesthesia residents using tracheal tube preloaded over Frova introducer (n = 70) or without Frova introducer (n = 70). Primary outcome was the intubation time. Secondary outcomes were the number of redirections of tracheal tube or Frova introducer toward glottis, need for external laryngeal maneuvers (ELMs), first attempt intubation success rate, and ease of intubation.Results:The median actual intubation time (IQR) in Frova and non-Frova group, respectively, were 25.46 (28.11–19.80) and 19.96 (26.59–15.52) s (P = 0.001). The number of redirections of TT or Frova introducer toward glottis, first attempt success rate, and ease of intubation were comparable. The need for ELMs [n (%)] was 15 (21.4) and 26 (37.1) in Frova and non-Frova group, respectively (P = 0.04).Conclusion:Frova introducer guided endotracheal intubation with C-MAC videolaryngoscope in patients with normal airways had a marginally prolonged intubation time with a significant reduction in the need of external laryngeal manoeuvres but with a comparable number of redirections and attempts. Further research is needed to generalize these findings to patients with difficult airways.

Between the devil and the deep red sea: Airway trauma during introducer-guided difficult intubation

Difficult airway management and difficult intubation can be challenging in any setting but are especially so in the pre-hospital (1), emergency department and intensive care environments. Over the last few decades, a number of devices have been introduced into clinical practice to deal with this challenge. However, very few devices have withstood the test of time better than tracheal tube introducer (bougies).

The tracheal tube introducer, known as the bougie, is typically used to aid tracheal intubation in poor laryngoscopic views or after intubation attempts fail. The effect of routine bougie use on first-attempt intubation success is unclear. To compare first attempt intubation success facilitated by the bougie vs the endotracheal tube + stylet. The Bougie Use in Emergency Airway Management (BEAM) trial was a randomized clinical trial conducted from September 2016 through August 2017 in the emergency department at Hennepin County Medical Center, an urban, academic department in Minneapolis, Minnesota, where emergency physicians perform all endotracheal intubations. Included patients were 18 years and older who were consecutively admitted to the emergency department and underwent emergency orotracheal intubation with a Macintosh laryngoscope blade for respiratory arrest, difficulty breathing, or airway protection. Patients were randomly assigned to undergo the initial intubation attempt facilitated by bougie (n = 381) or endotracheal tube + stylet (n = 376). The primary outcome was first-attempt intubation success in patients with at least 1 difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). Secondary outcomes were first-attempt success in all patients, first-attempt intubation success without hypoxemia, first-attempt duration, esophageal intubation, and hypoxemia. Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups. In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings. clinicaltrials.gov Identifier: NCT02902146.

Background:The aim of this study was to examine the application of the Eschmann tracheal tube introducer (ETTI) with 4 types of supraglottic airway devices (SADs) using a child-manikin.Methods:A total of 79 paramedics were asked to exchange the 4 SADs for an endotracheal tube with the ETTI in 3 different scenarios using a randomized crossover study format: normal airway without chest compression; normal airway with uninterrupted chest compression; and difficult airway with uninterrupted chest compression. The primary outcome was time to SAD exchange, with the secondary outcome measuring the success of SAD exchange. Each attempt was assessed by a trained assistant.Results:The mean exchange times for LMA, Cobra PLA, Air-Q, and SALT were as follows: 21, 23, 21, and 18, respectively for Scenario A; 23, 27, 22.5, and 21 for Scenario B; and 23, 28, 23, and 23 for Scenario C. The percent efficacy of SADs exchange with LMA, Cobra PLA, Air-Q and SALT were 98.7%, 94.9%, 100%, and 100% for scenario A; 98.7%, 88.6%, 98.7%, and 97.5% for scenario B; and 93.7%, 87.3%, 94.9%, and 93.7% for scenario C.Conclusions:In this model of pediatric resuscitation, the SAD exchange using an ETTI has (LMA, Cobra PLA, Air-Q and SALT) proved to be effective in paramedics with no previous experience. Furthermore, experimental findings indicated that SAD exchange can be achieved without interrupting chest compression.