Expert: Dr Ian Jackson - please note UK based - 9/21/2008

Question
Hello,
I am working for an emergency medical service and recently the idea of placing bougies on our ambulances to aid in difficult intubations as we frequently end up in situations where it can be quite hard to place a tube.  I am somewhat familiar with how they function, but what I am looking for some stats or information to support adding the expense specifically improved intubation rates.  I have spoken with several flight services which have informed me they feel it is beneficial, but they can't really give me a comparisson as they always have them available and if they predict a difficult airway they have them at their disposal (as I'm sure you do).  But how exactly will they benefit in difficult intubations and is there a better or more beneficial assisting device focused towards bull necked or obese patients which are our typical "difficult intubations"?  Thank you so much for your insight.

Answer
Hi there
Oh this is a very difficult topic and has caused consternation across the UK with Paramedics. I have for years trained people to use bougies when they find themselves in a difficult intubation situation. It is not a panacea and there will still be patients you cannot intubate, however if you have been trained to use them they can help.
I suppose there is a bit of an issue now with the availability of supraglottic airways such as the laryngeal mask - but that is another whole different issue!
I am not aware of any stats on this. Despite being a full BASICS doctor I seldom intubate on scene and so far have not had to use one but I always carry one in my kit.
I train people to attempt intubation normally first and if they run into difficulty but can see at least the epiglottis and are able to lift it forward then they can try with the bougie. Usually for the non experienced they should at least be able to see the posterior aspect of the larynx (the arytenoids) so they know where to aim for.
Once the bougie is in place they should keep the larygoscope in place and have an assistant pass the ET tube over the BOugie and then the assistant should hold onto the top of the bougie so it doesn't get pushed in further. The operator can then pass the ET tube into the larynx - this is often helped with a slight twisting motion - while trying to keep the epiglottis forward with the laryngoscope.
Works a treat in the right circumstances.
Hope this helps a bit, sorry no stats!
Dr Ian Jackson