Bougie-assisted difficult airway management in a manikin ? the effect of position held on placement and force exerted by the tip

Double-lumen tracheal tubes and bougies: a bench study to investigate factors that influence the risk of shearing

Tracheal intubation with a double-lumen tube can be more challenging than with a single-lumen tube. A bougie can be used to facilitate intubation. Case reports have described fragment shearing from bougies when they are removed from the tube after intubation. These fragments have the potential to cause harm. It has even been suggested that bougies and double-lumen tubes should not be used together. We conducted a benchtop trial to investigate factors that influence the risk of shearing. We investigated three brands of double-lumen tube (each in three sizes and both lateralities) and four brands of bougie. We simulated one intubation and 29 further insertions/removals of bougie with every bougie-double-lumen tube combination. We inspected the inside of the tube for evidence of shearing after first, tenth and thirtieth removals. We found that brand of bougie, brand of double-lumen tube and size of double-lumen tube (but not its laterality) all influenced the degree of shearing. Certain bougie-double-lumen tube combinations produced a particularly high degree of shearing, so these should be avoided.

Radical evolution: the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation

There is little doubt that these guidelines incorporate advances made in airway management since 2004. They will change day-to-day practice of anaesthesia, as outlined above, from pre-operative airway assessment, to integrating the WHO team briefing, to the use and provision of equipment and drugs, and the recording of information on the anaesthesia chart. They will inform the later analysis of any critical airway incidents, especially as documentation and postoperative management are addressed, and they will encourage training in a range of techniques. Taken together, not quite a revolution but certainly a very 'radical evolution'.Assessment of the utility of the new guidelines should consider if they can be used as tools to enhance knowledge and training, or in addition as a prosthesis to bridge the gap between the requirements of and our abilities during emergencies. Formal testing may reveal which aspects of their design, complex as it is, may distract from, rather than enhance, airway management during crises.All guidelines represent a standard of care or a normative approach to a clinical problem. As such, they not only help guide clinicians, but they also provide the broader community with the opportunity to improve standards, to ensure equipment is available, and that training for the skills and processes required are in place to ensure successful adoption.

Bougie-related airway trauma: dangers of the hold-up sign

The bougie is a popular tool in difficult intubations. The hold-up sign is used to confirm tracheal placement of a bougie. This study aimed to establish the potential for airway trauma when using this sign with an Eschmann re-usable bougie or a Frova single-use bougie. Airways were simulated using a manikin (hold-up force) and porcine lung model (airway perforation force). Mean (SD) hold-up force (for airway lengths over the range 25-45 cm) of 1.0 (0.4) and 5.2 (1.1) N were recorded with the Eschmann and Frova bougies, respectively (p < 0.001). The mean (SD) force required to produce airway perforation was 0.9 (0.2) N with the Eschmann bougie and 1.1 (0.3) N with the Frova bougie (p = 0.11). It is possible to apply a force at least five times greater than the force required to produce significant trauma with a Frova single-use bougie. We recommend that the hold-up sign should no longer be used with single-use bougies. Clinicians should be cautious when eliciting this sign using the Eschmann re-usable bougie.

Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single-use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single-use bougie, 16/60 (27%) using a Frova single-use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device.

Retrograde intubation

Airway management in the emergency department is a critical skill that must be mastered by emergency physicians. When rapid-sequence induction with oral-tracheal intubation performed by way of direct laryngoscopy is difficult or impossible due to a variety of circumstances, an alternative method or device must be used for a rescue airway. Retrograde intubation requires little equipment and has few contraindications. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.

Intubation bougie dissection of tracheal mucosa and intratracheal airway obstruction

Intubation bougies are commonly used to aid in intubation when an optimal view of the larynx is not obtained. We describe a case of tracheal perforation using a disposable intubation bougie resulting in a complete intratracheal airway obstruction relieved by cricothyrotomy. Disposable intubation bougies may have mechanical properties that differ from their nondisposable counterparts making complications more likely.

The effect of temperature on bougies: a photographic and manikin study

We investigated the effect of temperature on single use and reuseable bougies. In a photographic study, three bougies (Portex Venn reuseable (R), Portex single use (S) and Breathesafe single use (B)) were exposed to increasing temperatures and sequential photographs were taken of the bougies uncoiling from a preformed curve. Bougie type was associated with rate of uncoiling, type R maintaining its curve the longest but changing temperature did not affect this. In a randomised cross-over manikin study, 16 anaesthetists attempted to pass two bougies (Portex reuseable (R) and Portex single use (S)) at three temperatures (10, 20 and 30 degrees C) into the trachea of a manikin. Type R was significantly associated with higher success rate of tracheal placement compared to type S. Change of temperature was significant with success rate increasing with lower temperature. The odds of success at 10 degrees C was six times that at 30 degrees C (OR (95%) 6.7 (1.7, 25.7)). We concluded that both bougies performed best at 10 degrees C.

Comparison of the Levitan FPS Scope and the single-use bougie for simulated difficult intubation in anaesthetised patients

A randomised cross-over study was performed in 34 patients with no evidence of airway difficulties, following induction of general anaesthesia, to compare the efficacy of the Levitan FPS scope (LFPS) and the single-use bougie for tracheal intubation during simulated grade IIIa laryngoscopy. Success rates for intratracheal placement of the device, and the time required for insertion and tracheal intubation were recorded. Both devices were equally successful (31/34 for the LFPS vs 29/34 for the bougie) for insertion into the glottis. The mean insertion time for the LFPS was statistically longer than that for the bougie (4.4-12.5 s) but this difference was not clinically relevant. Intubation times were similar between the two devices. Major problems hindering successful intubation using the LFPS were the presence of a narrow epiglottic-pharyngeal wall space and copious secretions. An inability to maintain the desired shape was the principal cause of failure with the bougie.

Prehospital airway management in Ambulance Services in the United Kingdom

A postal survey of the 38 Ambulance Services in the United Kingdom was undertaken to find out what equipment is provided for paramedic crews to aid tracheal intubation and to confirm tracheal placement. The response rate to our survey was 100%. Fourteen (37%) ambulance services provided neither stylet nor bougie to facilitate difficult intubation. The laryngeal mask airway was available to 15 (40%) ambulance services. Seventeen (45%) ambulance services had use of a needle cricothyroidotomy set. Twenty-nine (76%) ambulance services had no type of device other than a stethoscope to confirm tracheal tube placement. This survey showed wide variations in the equipment for airway management available to paramedic crews in the United Kingdom. We recommend provision of a standard set of airway management equipment to all paramedic crews in the United Kingdom together with introduction of appropriate training programmes.

Evaluation of Frova, single-use intubation introducer, in a manikin. Comparison with Eschmann multiple-use introducer and Portex single-use introducer

In a randomised cross-over study, 48 anaesthetists attempted to place a Frova single-use introducer, an Eschmann multiple-use introducer and a Portex single-use introducer in the trachea of a manikin set up to simulate a grade 3 laryngoscopic view. The anaesthetists were blinded to success (tracheal placement) or failure (oesophageal placement). Successful placement (proportion, 95% confidence interval) of either the Frova introducer (65%, 50-77%) or the Eschmann introducer (60%, 46-73%) was significantly more likely than with the Portex introducer (8%, 3-20%). There were no significant differences between the success rates for the Frova and the Eschmann introducers. A separate experiment revealed that the peak force exerted by the Frova and Portex introducers was two to three times greater than that which could be exerted by the Eschmann introducer, p < 0.0001, indicating that the single-use introducers are more likely to cause tissue trauma during placement.