While the Europeans are steadfastly married to their bougies, Americans pioneered the use of stylets to aid in shaping and inserting tracheal tubes. Tracheal tubes have an inherent arcuate shape as a consequence of the way they are formed. This arcuate shape, with a wide side-to-side dimension, is not ideal for insertion into the narrowing confines of the upper airway, which Sir Macintosh appreciated. Minor rotation of the tube causes major lateral movement of the distal tip, and combined with blocking of the view, this a contributing factor in tube misplacement during direct laryngoscopy. A styletted tube, however, can be shaped into a long narrow axis shape, with a bend angle that respects the dimensions of the trachea (straight to cuff and 35 degrees, see Figure 2). When placed into this shape, I find that the distal tip of such a tube can be placed from below the line of sight, and tube insertion does not need to obscure the cords. I have carried a bougie in my airway tool kit for more than 15 years, and I have never deployed it in anger; I became obsessed with stylet shaping. A styletted tube can also be inserted faster (tube placed, stylet withdrawn) compared to a bougie intubation, which is generally a three-step process of bougie insertion, tube railroading, and bougie withdrawal.

Despite my enthusiasm for a straight-to-cuff stylet, I think a bougie should be part of every airway kit. It can be useful in situations of poor laryngeal exposure, for placement into a trach, or in an emergent cric. The single-use versions are inexpensive. Some users complain it is hard to store because of its long length, about 60 cm. I address that issue by folding it in half. Bending the bougie and using a rubber band to keep it in this bent-over shape allows it to fit in intubation trays, draws, and jump bags. More important, when it is pulled out, this bent shape allows good control and preserves the long axis narrow dimension of the distal tip as it is inserted. Although the Pocket bougie is easy to carry, straightening may be needed depending on its intended use (especially for direct laryngoscopy).

Figure 1. Bougies and tube introducers: Tracheal tubes have an inherent arcuate shape (top). A malleable stylet can optimally shape a tube to be straight-to-cuff (35 degree bend, second from top). Bougies have long narrow axes with an upturned distal tip (Frova, blue color, allows for insufflation) and Smiths-Portex original design (resin covered fiberglass, beige). Cook Critical Care tracheal tube exchange catheter (straight shape, hollow bore for insufflation, second from bottom). The GlideRite stylet is used with a hyperangulated video blade to get the tube around the tongue, but has too wide a side-to-side dimension to insert into the trachea (bottom).
Figure 2. Straight-to-cuff styletted tube. Note the narrow long-axis view. There is a 35-degree bend at the proximal cuff. The stylet stops at the distal cuff, leaving the last few centimeters of the tube pliable.
Figure 3. The Shake grip: By folding the bougie in half and gripping the bougie this way, it is easy to determine the direction of the distal tip, prevent tube rotation, and achieve fine control of the device.