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Podcast 58 - Bougie Pitfalls & Tongue Control

Bougie Era

We all have grown to love the bougie, and many are rightfully utilizing it on their first attempt to optimize success. However, just like we found with the cool kid ketamine, if not done right you can meet some difficulty. The tool is only as good as its handler. In this podcast we will discuss a few tips, tricks, and pitfalls of becoming a bad@$$-bougie-master. 

Don't store it curled up.. (or it ends up looking like this..yes that's JimmyD)

When I first got the bougie implemented at Lifestar EMS I kept them stored in a curved shape in the airway bag. My thought was that this would help approach the "anterior" airway. That was until I pulled out the bougie to intubate one day and found it looking like the one Jim is holding below. The bougie should be stored as straight as possible to avoid awkward twists and bends that will be tough to smooth out during resuscitation. My advice is to store the bougie straight or with a very soft curve. You can always shape it as needed prior to intubation. Its a lot harder to straighten it than it is to curve it.

Unchanneled hyper-angulated blades are best served with a rigid stylet (slot-machine maneuver)

Yes, it can be done with a curved bougie, but it seems to be met with more challenges when it comes to finding just the right pitch. The problem is that the hyper-angulated blades are typically "non-tissue displacing". This means the camera is meant to just peak around the corner and avoid the need to align the oral axis with the laryngeal axis. This is fantastic for patients who have spinal precautions and ear to sternal notch (E2SN) is not feasible. However, the tube will still need to negotiate around the tongue and into the larynx. Without a rigid stylet this can be extremely difficult to manage.

Don't remove the blade until the ETT is in, cuff is inflated, and bougie is withdrawn...

I can't emphasize this enough! Too often I see clinicians pass the bougie, and then remove the blade as if they are finished. The ETT often gets hung up on the surrounding structures of the larynx. This is better negotiated when you can see the obstruction. It is also worth mentioning that occasionally inflating the cuff can migrate the tube proximal. You do not want the balloon to be muffin topping out of the larynx. Keep the blade in the mouth until the very end.

If your bougie gets hung up on the epiglottic tubercle or anterior larynx rotate the proximal end of the bougie.

As mentioned above, its not uncommon for the bougie to get hung up on the arytenoids or epiglottic folds. Not only can the bougie get hung up, but the tube as well. I recommend always sticking with a counterclockwise turn. This will allow the bevel portion of the tube to easily ramp over the arytenoids. I find it easier to manipulate a tube from the most proximal end. This is pretty much right at the 15mm adapter. 

Utilize tongue depressor or suction catheter to displace tongue/mandible anterior prior to placing the blade in the mouth.

I've noticed the most awkward part of watching someone else intubating, is seeing them open the mouth and enter the blade. It just rarely seems smooth, and there is a few seconds they spend trying to get the blade to the posterior portion of the tongue. This view is usually just wet and pink. I like to avoid this by utilizing a suction catheter or tongue depressor to distract the tongue anterior and against the mandible. This allows me to snake my blade right past that stupid tongue. I do however still recommend and incremental approach. Just now you don't have to spend those increments fighting the pink monster.

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