In the world of airway devices, there are few that have more fans than the beloved bougie. Although it has a British history—it was first described in 1949 by Sir Robert Macintosh, a New Zealander who moved to Britain—it seems wherever I travel people love their bougies. In many of the Commonwealth countries and throughout most of Europe, airway managers treat this device as mandatory for tube insertion. Enthusiasts promote it for direct and video laryngoscopy, the “bougie-aided cric,” and placement through supraglottic airways. Some folks believe it has magical magnetic properties that guide it exclusively into the trachea (not true).
Explore This IssueACEP Now: Vol 33 – No 09 – September 2014
During direct laryngoscopy, Sir Macintosh observed, “One of the difficulties in passing tubes beyond a certain size is that the body of the tube obscures the view of the cords through which the tip must be directed.” He described use of a “gum-elastic catheter,” which he passed through the cords first, followed by the tracheal tube. Although Sir Macintosh’s device was straight, he described shaping it into a curve to aid in cases of poor laryngeal exposure. Portex subsequently developed a tracheal tube introducer with a Coudé tip made of resin-covered fiberglass, but somehow the device has been labeled the “gum elastic bougie” despite that it is neither gum, elastic, nor a bougie (ie, a dilator). The Portex device can be reprocessed, but as the world of airway devices became disposable, a variety of companies introduced single-patient use plastic “bougies” with both straight and Coudé tip designs, such as one by SunMed USA in Grand Rapids, Michigan (see Figure 1). Not only are bougies available in different colors of plastic, there are different versions with special features, such as the Frova catheter by Cook Medical Critical Care in Bloomington, Indiana, and the Introes Pocket Bougie by BOMImed in Bensenville, Illinois. The Frova has a hollow lumen, allowing for oxygen insufflation; the Pocket bougie is made of Teflon and packaged in a rolled shape to fit into a pocket. Bougies are also available in a pediatric version, such as the 10 Fr compared to the 15 Fr diameter bougie from SunMed USA.
So what is magical about the bougie? Why the love affair? The bougie has three distinguishing characteristics that make it a useful adjunct for tube delivery. First, it has a smaller outer diameter than a tracheal tube. Most bougies are 5 mm (15 Fr); a tracheal tube of 7.5 mm inner diameter is almost twice as large in outer diameter as a bougie. Second, the upturned distal tip of the bougie, originally with a 38-degree bend angle, has an overall long axis dimension that does not exceed the dimensions of the trachea. The trachea is more narrow than most clinicians realize. In females, it is only 14–16 mm; in males, 15–20 mm. Because of the bougie’s flexibility and rounded distal tip, it usually passes into the trachea without hanging up on the tracheal rings. Finally, there is its tactile feel of the trachea on insertion. In 90 percent to 95 percent of cases, the bougie provides detection of the “rumble strip” of the anterior tracheal rings, assuming the tip is oriented anteriorly. The posterior membranous trachea is flat, so in order to appreciate the rings, the tip has to be properly oriented.