Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.59 no.5 Campinas Sept./Oct. 2009
Leonardo de Andrade Reis, M.D.I; Guilherme Frederico Ferreira dos Reis, TSA, M.D.II; Milton Roberto Marchi de Oliveira, M.D.I; Leandro El Bredy Ingarano, M.DI
IInstrutor Convidado do CET/SBA Casa de Saúde Campinas
IIResponsável pelo CET/SBA Casa de Saúde Campinas
BACKGROUND AND OBJECTIVES: Difficult airways require fast action by the anesthesiologist often requiring complementary devices to ensure patent airways. However, several of those devices are expensive and require training in order to be used. The bougie, a simple and disposable device can also be manufactured by the anesthesiologist, making it a low cost tool.
CONTENTS: Bougies are composed of one introducer that when inserted in the trachea helps orienting the introduction of the tracheal tube. It is a simple tool, easy to use, low in cost, and has been shown to be very useful in unexpected difficult airways.
CONCLUSIONS: The bougie has shown to be a valuable tool in the armamentarium of the anesthesiologist, and it is indicated in a wide range of situations.
Keywords: ANESTHESIA, General; INTUBATION, Tracheal.
JUSTIFICATIVA Y OBJETIVOS: Las situaciones de vía aérea difícil obligan al anestesiólogo a actuar rápidamente, muchas veces necesitando dispositivos complementarios para garantizar la permeabilidad de esas vías. Sin embargo, muchos de esos dispositivos son caros y necesitan un entrenamiento para su uso. Aquí presentamos un dispositivo sencillo, desechable y que puede ser confeccionado por el mismo anestesiólogo, convirtiéndolo así en una herramienta de bajo coste: el bougie.
CONTENIDO: El bougie es un introductor que insertado en la tráquea, ayuda a orientar la inserción de la cánula traqueal. Por ser una herramienta muy sencilla, de fácil manejo y de bajo coste, es muy útil en las situaciones de vía aérea difícil inesperada.
CONCLUSIONES: El bougie fue una valiosa herramienta en el arsenal anestesiológico, siendo muy bien indicada en una amplia gama de situaciones.
The bougie, also known as Frova or Gum Elastic Bougie, consists of an auxiliary, introducer-type device for tracheal intubation widely used in Europe because it is inexpensive, simple, easy to use1, and very versatile. It can be used in different situation and will be presented here. It is an invaluable tool in the unexpected difficult airway, and the first choice of anesthesiologists in the United Kingdom2,3. Currently, several guidelines for the airways suggest their use4-6. In English, the word bougie means candle, a device used to dilate structures, which does not correspond to the use of this tool; besides, the material is not elastic as suggested by the term elastic, and it is not made of resins as suggested by the term gum7.
The first bougie used as a tracheal intubation aid was described by Macintosh in 19498 by using a urethral dilation catheter9 and since then it has been used for several purposes. In 1970, the introducer was modified by Venn7, with an angulation between 35º and 40º of the distal end (a shape known as coudé) 9,10 creating the characteristic shape still in use nowadays.
Currently, several types of introducers are called bougie including the disposable (single use), reusable (multiple use), and homemade. Reusable bougies are made of a more flexible material, have a globose and round tip, and can be used up to five times10,11. The disposable bougie is made of a more rigid material with a straight tip, and it has a central channel that can be used for aspiration or to administer oxygen. The homemade introducer can be made using a 60-cm piece of a cord introducer, which is found in hardware stores very similar to an electrical cord but without the metal inside. It is made of nylon, it can be cut and its extremity can be sanded to make it less traumatizing.
To use the handmade or the reusable device, it is important to follow disinfecting standards. The material should be washed in a solution of water and neutral soap to remove all residues, including secretions and blood. Afterwards, it should be submerged in a disinfecting solution and sent for sterilization. The device should be stored in the original wrapping and protected from light. Cupitt demonstrated a significant incidence in the contamination of bougies that are not properly stored10.
USES AND TECHNIQUES
Multiple uses of the bougie have been described in the literature; among them we should mention intubation of the unexpected difficult airway12-14, change of tracheal tubes, guiding rigid bronchoscopes15, and the insertion of double-lumen tracheal tubes16-17 and laryngeal masks18,19. It is not as effective as the fiberscope in the intubation of patients with known difficult airways2. In unexpected difficult airways, it is superior to the lighted stylet3 since it is easier to manipulate and it does not require extensive training20 despite being associated with a higher incidence of failed intubation2. Hammarskjöld21 described in 1999 the introduction of a seethrough-bougie-guided fiberoptic bronchoscope. Once inside the trachea, the fiberoptic bronchoscope was removed and the introducer remained inside the trachea to guide the introduction of a tracheal tube.
In unexpected difficult airways in patients Cormack 2 to 4, the bougie can be introduced directly into the trachea under laryngoscopy. If the vocal cords are not visible and the epiglottis is partially visible, it can be used to locate the tracheal opening below the epiglottis. After placing it inside the trachea, it should be introduced gently to avoid traumatism until impacting in the airways. When introducing it in the trachea, the anesthesiologist should feel the characteristic clicks caused by sliding its extremity over the tracheal rings. If those clicks are not felt, it should be considered the possibility of esophageal insertion22. Once in the trachea, laryngoscopy is maintained and, if possible, with the help of an assistant, the tracheal tube should be introduced through the bougie using a 90º anti-clockwise rotation to prevent its beveled point from getting caught in the arythenoids23, and then remove the bougie. Weisenberg13 described the use of a mirror placed in the larynx to help visualize the introduction of the device. The author observed a lower incidence of failure when using indirect laryngoscopy.
A consensus among anesthesiologists on the best way to hold the bougie does not exist. Hodzovic24 compared the easiness to introduce the device when it was held at 20 and 30 cm from the extremity, and concluded that holding it at 20 cm allowed greater control and faster introduction, but the pressure on the walls of the airways was considerably higher increasing the probability of injuries. A controversy on the compression of the cricoid cartilage also exists. This maneuver seems to facilitate the introduction of the device24, but during progression of the tracheal tube the effect can be the opposite.
The bougie can be used to change the tracheal tube although a version for this end called "tracheal tube exchanger" is available. In this case, the device is introduced through the tracheal tube to be changed, the old one is removed and with the help of laryngoscopy the new ET tube is introduced according to the technique described.
Several descriptions on the use of the bougie to help inserting the laryngeal mask can be found in the literature, being inserted through conventional masks or ProSealT mask. During a difficult intubation in which the bougie is suddenly introduced in the esophagus, it can be used to guide the introduction of the laryngeal mask25. Lopez-Gil20 described the intentional introduction of the device in the esophagus under laryngoscopy to orient the introduction of the laryngeal mask. On this paper, it was not clear the advantage of laryngoscopy to introduce the bougie and then the laryngeal mask instead of tracheal intubation. The association of this device with the laryngeal mask is also described in the literature during intubation failures, when the anesthesiologist introduces the laryngeal mask to ventilate the patient and then uses it to introduce the bougie in the airways19,26,27.
During rigid bronchoscopy, it is extremely difficult to introduce the bronchoscope in some patients. Multiple accesses to the airways might also be necessary due to several device changes, and tracheal dilation and intubation at the end of the procedure. Bleeding and edema hinder successive intubations. In those cases, the bogie has shown to be effective15,16 (Figure 1).
Although it is widely used in Europe1, few complications have been reported in the medical literature placing an apparent notion of safety. Complications can be divided into three groups: failure of the material, traumatic, and biological.
Among complications related to the material, bougie breakage with or without the loss of fragments in the airways have been reported. In 2002, Gardner28 described the detachment of the tip of the bougie during intubation, which required bronchoscopy to remove the fragment from the airways. Similar cases were seen in 199911 and 199520, indicating the need to inspect the material especially of reusable bougies before their use. The reusable device should only be used five times due to parching of the material, leading to weakens and possible fracture of the device.
Among traumatic complications, severe bleeding in the airways30,31 after the use of the bougie should be emphasized. However, the reports of pharyngeal perforation32, esophageal lacerations, and pneumothorax33,34 are more severe. During the manufacture of a homemade device, its extremity can be coarse and with projections, which are potential sources of traumatism. Therefore, although it is a simple device, caution should be exerted when using it. Disposable bougies also seem to be potentially more traumatic25 and less effective35,36 than reusable devices because their tip is not rounded and exerts more pressure on the walls of the airways.
Transmission of diseases and infections has also been reported especially with reusable bougies indicating the need for adequate care during storage and disinfection10.
The bougie is a cheap, easy to use, and successful device when used in unexpected difficult airways. This simple tool should be part of the basic anesthesiology armamentarium and be available in all operating rooms. In emergency situations, it has shown to be capable of helping fast intubation, guaranteeing opened airways, surpassing more sophisticated devices such as the lighted stylet and fiberoptic bronchoscope. However, in order to use it, the anesthesiologist should make sure it has been properly disinfected. It should be introduced gently to decrease the risks of breakage of the material or airways injury. It requires someone's help because the anesthesiologist should maintain laryngoscopy during the introduction of the bougie and ET tube.
01. Latto IP, Stacey M, Mecklenburgh J et al. - Survey of the gum elastic bougie in clinical practice. Anaesthesia, 2002;57:379-384. [ Links ]
02. Hames KC, Pandit JJ, Marfin AG et al. - Use of the bougie in simulated difficult intubation. 1. Comparison of the single-use bougie with the fibrescope. Anaesthesia, 2003:58:846-851. [ Links ]
03. Gataure PS, Vaughan RS, Latto IP - Simulated difficult intubation: comparison of the gum elastic bougie and the stylet. Anaesthesia, 1996;51:935-938. [ Links ]
05. Braun U, Goldmann K, Hempel V et al. - Practice guideline: airway management. Anästh Intensivmed, 2004;45:302-306. [ Links ]
06. Henderson JJ, Popat MT, Latto IP et al. - Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaestesia, 2004;59:675-694. [ Links ]
07. Henderson JJ - Development of the "gum elastic bougie". Anaesthesia, 2003;58:103-104. [ Links ]
08. Macintosh RR - An aid to oral intubation. BMJ, 1949;1:28. [ Links ]
09. El-Orbany MI, Salem MR, Joseph NJ - The Eschmann tracheal tube introducer is not gum, elastic, or a bougie. Anesthesiology, 2004;101:1240. [ Links ]
10. Cupitt JM - Microbial contamination of gum elastic bougies. Anaesthesia, 2000;55:466-468. [ Links ]
11. Latto P - Fracture of the outer varnish layer of a gum elastic bougie. Anaesthesia, 1999;54:497-498. [ Links ]
12. Morton G, Chileshe B, Baxter P - Gum elastic bougie in the hole technique. Anaesthesia, 2002;57:1037-1038. [ Links ]
13. Weisenberg M, Warters RD, Medalion B et al. - Endotracheal intubation with a gum-elastic bougie in unanticipated difficult direct laryngoscopy: a comparison of a blind technique versus indirect laryngoscopy with a laryngeal mirror. Anesth Analg, 2002;95:1090-1093. [ Links ]
14. Orelup CM, Mort T - Airway rescue with the bougie in the difficult emergent airway. Crit Care Med, 2004,32:A118 [ Links ]
15. Nekhendzy V, Simmonds PK - Rigid bronchoscope-assisted endotracheal intubation: yet another use of the gum elastic bougie. Anesth Analg, 2004;98:545-547. [ Links ]
16. Baraka A - Gum elastic bougie for difficult double-lumen intubation. Anaesthesia, 1997;52:929. [ Links ]
17. Weller RM - Gum elastic bougie for difficult double-lumen intubation. Anaesthesia, 1998;53:311. [ Links ]
18. Gajraj NM - Tracheal intubation through the laryngeal mask using a gum elastic bougie. Anaesthesia, 1996;51:796. [ Links ]
19. Lopez-Gil M, Brimacombe J, Barragan L et al. - Bougie-guided insertion of the ProSealtm laryngeal mask airway has a higher first attempt success rate than the digital technique in children. Br J Anaesth, 2006;96:238-241. [ Links ]
20. Evans A, Morris S, Petterson J et al. - A comparison of Seeing Optical Stylet and the gum elastic bougie in simulated difficult intubation: a manikin study. Anaesthesia, 2006;61:478-481. [ Links ]
21. Hammarskjöld F, Lindskog G, Blomqvist P - An alternative method to intubate with laryngeal mask and see-through-bougie. Acta Anaesthesiol Scand, 1999;43:634-636. [ Links ]
22. Dagg LE, Jefferson P, Ball DR - "Hold up" and the gum elastic bougie. Anaesthesia, 2003;58:103. [ Links ]
23. McNelis U, Syndercombe A, Harper I et al. - The effect of cricoid pressure on intubation facilitated by the gum elastic bougie. Anaesthesia, 2007;62:456-459. [ Links ]
24. Hodzovic I, Wilkes AR, Latto IP - Bougie -assisted difficult airway management in a manikin - the effect of position held on placement and force exerted by the tip. Anaesthesia, 2004;59:38-43. [ Links ]
25. Brimacombe J, Howath A, Keller C - A more "failsafe" approach to difficult intubation with the gum elastic bougie. Anaesthesia, 2002;57:292. [ Links ]
26. Murdoch JAC - Emergency tracheal intubation using a gum elastic bougie through a laryngeal mask airway. Anaesthesia, 2005;60:626-627. [ Links ]
27. Sarma J - Intubating using an LMA and gum elastic bougie. Anesth Analg, 2006;102:975. [ Links ]
28. Gardner M, Janokwski S - Detachment of the tip of a gum-elastic bougie. Anaesthesia, 2002;57:88-89. [ Links ]
29. Robbins PM, Hack H - Critical incident with gum elastic bougie. Anaesth Intensive Care, 1995;23:654. [ Links ]
30. Prabhu A, Pradhan P, Sanaka R et al. - Bougie trauma: it is still possible. Anaesthesia, 2003;58:811-813. [ Links ]
31. Heidemann BH, Clark VA - Tracheal trauma secondary to the use of a Portex single-use bougie. Anaesthesia, 2004;59:1043-1044. [ Links ]
32. Kadry M, Popat M - Pharyngeal wall perforation: an unusual complication of blind intubation with a gum elastic bougie. Anaesthesia, 1999;54:404-405. [ Links ]
33. Hodzovic I, Latto IP, Henderson JJ - Bougie trauma - what trauma? Anaesthesia, 2003;58:192-193. [ Links ]
34. Lima LG, Bishop MJ - Lung laceration after tracheal extubation over a plastic tube changer. Anesth Analg, 1991;73:350-351. [ Links ]
35. Marfin AG, Pandit JJ, Hames KC et al. - Use of the bougie in simulated difficult intubation. 2. Comparison of single-use bougie with multiple-use bougie. Anaesthesia, 2003;58:852-855. [ Links ]
36. Annamaneni R, Hodzovic I, Wilkes AR et al. - Comparison of simulated difficult intubation with multiple-use and singe-use bougies in manikin. Anaesthesia, 2003;58:45-49. [ Links ]
Correspondence to: Submitted em 31 de janeiro de 2009
Dr. Leonardo de Andrade Reis
Rua Ferreira Penteado, 1338/94
13010-907 Campinas, SP
Accepted para publicação em 20 de maio de 2009
Submitted em 31 de janeiro de 2009