In an epiglottis-only view, always perform bimanual laryngoscopy (either with direct or video laryngoscopy) to try to visualize the interarytenoid notch, then direct the bougie tip over it to ensure you’re entering the trachea and not the esophagus. In the true epiglottis-only situation, make sure you keep the distal tip up (and feel the rings) as it can easily rotate under the epiglottis and miss the larynx.

The bougie has historically been held with a pencil grip. I find this not an easy way to keep it from rolling over; I want to track which way the distal tip is pointing. Some versions of the bougie place their depth markings (usually every 10 cm) on the same side as the direction of the Coudé tip, but this is not universal.

Figure 4. The Kiwi grip: A one-handed means of inserting the tube and bougie together, and prevent sliding of the devices on each other. After the bougie tip is inserted, the operator drops the laryngoscope and uses his or her left hand to counterclockwise rotate the tube down the bougie into the trachea.
Figure 5. The Kiwi-D grip, Jim Ducanto’s method of inserting the bougie tip into the Murphy eye of the tube as a one handed means of tube-bougie insertion.
Figure 6. Close up of the Kiwi-D grip showing tip of bougie in Murphy eye.

I think the best way to grip the bougie is what I call the “Shaka” grip (see Figure 3). “Shaka” is the Hawaiian hand gesture with the middle fingers folded over that means “hang loose.” Gripping the device this way, the user has fine control and knows the direction of the distal tip, and the insertion end is the proper length, all of which helps avoid rolling over.

If you work in a setting where you do not have anyone to help with tube placement over the bougie (while you keep the direct or video laryngoscope retracting the tongue), you can use a one-handed bougie/tube grip. I first found out about this from Paul Baker, senior lecturer in the department of anaesthesiology at The University of Auckland in New Zealand and director at Airway Simulation Limited, but I have been since informed he learned of it from an Italian physician. I named it the “Kiwi” grip a few years ago (see Figure 4). With this grip, you place the bougie/tube with your right hand, and after entering the trachea with the exposed distal tip of the device, you drop your laryngoscope, hold the top of the bougie with your left hand, and roll the tube down the bougie into the trachea with your right hand. Jim Ducanto, an anesthesiologist from Milwaukee who has an incredible passion for education and imaging, devised the Kiwi-D grip (tucking the tip of the bougie into the Murphy eye, see Figures 5 and 6).