Thinking out loud.

I often struggle with… things.  Most things in fact.  In particular, thinking places no small degree of strain upon my dangerously limited capacities.  In spite of this I have been thinking lately.  Thinking about bougies.  You know, those long, usually blue things us paramedics and EM types have a fetish for.  I’d like some help with my thinking about bougies so some feedback would be superb.

There seems to me to be a definite movement in the world of EM towards using the bougie as a first line tool in all intubations lately (check out this excellent video for an example)  The rationale is that you want to have the best chance at getting the tube in one go, and the bougie affords you that shot.  I appreciate that rationale.

But…  My thinking has always been a little different.  In my mind the bougie is the first tool in my rescue plan, the first step down the pathway of the failed intubation drill.  I thought:  what happens if I attempt intubation with the bougie and fail?  Where do I go then?  Of course I have a little play around with some external laryngeal manipulation, adjust my approach and so on.  But I’ve just failed with one tool, why should I expect to succeed trying again with the same tool?  If I had gone in straight with my tube (stylet in, straight to the cuff, my weapon of choice) and can’t pass the ETT, I then have a technique, a tool that changes things dramatically.

I do like the bougie and in fact used it just the other day in patient I thought was going to be a difficult tube: head injured, about to be RSI’d but short, fat, big shoulders, small jaw, and as it turns out, small mouth opening (the trismus made it hard to pick initially…)  Sure enough, grade 3 view, bougies away, success!  But most patients aren’t that tough.  Most are grade 1 or 2.  I still have the bougie loaded up ready to go in case I strike a tough airway that I didn’t predict, but it’s not my first tool.  I also appreciate that I need to have a degree of experience with the bougie so it is not an unfamiliar device when I really need it.  But every time?  Really?  Come on now!

So… is my thinking wrong?  Am I just stuck in a mindset that was implanted in my head back in the day, a slave to my conditioning?  Am I behind the times, should I drag myself out of the dark ages into the modern world of bougieland?  Or does my thinking have merit?  Are there some situations where going straight in with the bougie is not warranted or necessary?

Please, leave some feedback and let me know what you think.  Rest assured I am not just looking for validation of my thoughts, I genuinely am struggling with this issue.  I want to be the best I can be at airway management and I am concerned that I may be holding myself back.  So fire away, be candid, let me know your viewpoints or how you practice.

Robbie

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4 Responses to Thinking out loud.

  1. Seth Trueger says:

    I agree that most patients simply should have the bougie prepped and not used first line, but the idea that if you try and fail with the bougie then you have no 2nd line plan seems fallacious to me. There are few times when a bougie fails where a styletted tube would have worked – if you start at step 2 and fail, then your next step should be 3

  2. ambofoam says:

    Thanks for the reply Seth. I agree, there is no situation where one could reasonably expect an attempt sans bougie to succeed when an attempt with the bougie has failed. In the situation where an attempt with the bougie has been unsuccessful, how do you approach your next move?

    If a bougie attempt has failed, is it reasonable to try again with the bougie?, Or do we simply worsen our chances of success and risk becoming task focused to the detriment of the patient? Do we accept that our best shot has failed and move on to an EGD or other means of oxygenation? Or do we adjust our technique and try again once more (I generally hold to a two strikes rule)

    If you decide to try again, what parameters do you adjust prior to that attempt to maximise your chances at success? (These questions are for anyone reading, please feel free to chip in)

    Thanks for the feedback, I appreciate any comments.

  3. Seth Trueger says:

    I think you’re over thinking it. If you try with the bougie first and fail, it’s just as if you had tried with the bougie second and failed.

    I also think that laryngoscopy and placement need to be separated. Did bougie fail because you never got a view? (DL? VL?) Or, did you see nice cords but couldn’t get the bougie there?

  4. David says:

    I don’t think it makes a difference which way you proceed as long as you have a well thought out plan, communicated that plan with everyone else & stick to the plan. Personally, I’m not in favour of using a bougie with every intubation, but I certainly make sure I have a bougie immediately available at every intubation attempt (along with an SGA and equipment for a surgical airway). I regularly practice my failed airway drill on manikins, thereby maintaining my skill, and will use a bougie assisted intubation on patients occassionally for the practice.

    I think its a bit like putting an OP + 2 NPA’s in every patient that needs BVM. I have noticed it seems to be becoming an increasingly common practice for people to do this as a routine, when in my experience the overwhelming majority of patients can be managed without any of these adjuncts. My personal preference is to start with BVM using manual airway techniques and then progressively supplement with adjuncts as required.

    At the end of the day though I really think it is about having a coherent plan, communicating that plan to everyone involved & ensuring that the plan is followed.

    By the way excellent site!

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