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 Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 161-164

Lessons learnt from a difficult intubation scenario: Videolaryngoscopes cannot replace the humble bougie

Department of Anaesthesia, Guru Gobind Singh Medical College, Baba Farid University of Health Sciences, Faridkot, Punjab, India

Date of Submission09-Sep-2019
Date of Acceptance06-Nov-2019
Date of Web Publication30-Jan-2020

Correspondence Address:
Dr. Chandni Maheshwari
Department of Anaesthesia, Guru Gobind Singh Medical College, Baba Farid University of Health Sciences, Faridkot, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_29_19

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With the advent of videolaryngoscopes, the incidence of difficult intubation has decreased. Videolaryngoscopes are slowly replacing other airway gadgets such as the fibreoptic bronchoscope and intubating supraglottic devices, especially in institutions where they are freely available. These could not only be the first choice in anticipated difficult intubation but also the first rescue device in unanticipated difficult intubations. A failed intubation can occur despite obtaining a good view of the glottis with a videolaryngoscope. We were unable to intubate an anticipated difficult airway with C-MAC D-blade with a preformed hockey stick-shaped tube using a stylet despite using manoeuvres to optimise laryngeal view. The patient was finally intubated over a gum elastic bougie passed when retaining the videolaryngoscope in place. This case report highlights that a simple gum elastic bougie holds an equally important place on the difficult airway cart as a videolaryngoscope. The use of a gum elastic bougie should be considered as important as a videolaryngoscope in a difficult intubation scenario. It is reasonable to attempt the use of a bougie in the case of failed videolaryngoscope-assisted intubation before switching to another intubating device or a supraglottic airway. A dental consult for poor dentition should be taken prior to surgery whenever possible. Control of bleeding from a broken tooth needs to be done simultaneously and expeditiously even when we have visualised the glottis and are anticipating a successful intubation.

Keywords: Difficult intubation, failed intubation, gum elastic bougie, videolaryngoscope

How to cite this article:
Maheshwari C, Kavita D. Lessons learnt from a difficult intubation scenario: Videolaryngoscopes cannot replace the humble bougie. Airway 2019;2:161-4

How to cite this URL:
Maheshwari C, Kavita D. Lessons learnt from a difficult intubation scenario: Videolaryngoscopes cannot replace the humble bougie. Airway [serial online] 2019 [cited 2023 Mar 30];2:161-4. Available from: https://www.arwy.org/text.asp?2019/2/3/161/277326

  Introduction Top

Immediate access to difficult airway equipment is critical for the implementation of rescue strategies in difficult airway scenarios. The videolaryngoscope provides greater success after a first failed attempt at intubation and is increasingly being used as a first rescue device in case of unanticipated difficult intubations.[1],[2] Through our experience, we want to emphasise that a gum elastic bougie should be summoned simultaneously when a rescue device such as a videolaryngoscope is called for in a case of failed direct laryngoscopy. The All India Difficult Airway Association classifies the gum elastic bougie as mandatory equipment in the difficult airway cart, whereas videolaryngoscopes are placed under the desirable category depending on the economic condition of the health-care facility. There is ambiguity regarding what should be done first in case of failed direct or videolaryngoscope-assisted intubation – the use of a bougie or a change in intubating device.[3] Based on our experience of failed C-MAC-assisted intubation, use of a gum elastic bougie as the first choice is reasonable.

  Case Report Top

A 65-year-old female with no comorbidities was to be operated for ruptured intracranial aneurysm. On preoperative examination, she had a mouth opening of 2.6 cm, was predominantly edentulous with few buck teeth and loose upper incisor accompanied by periodontitis. In addition, there was also difficulty in neck extension, a short neck and modified Mallampati Class 4. The risk of tooth avulsion was explained to the patient and her relatives when taking consent for anaesthesia. We anticipated difficult ventilation as well as difficult intubation.

The patient was induced with propofol 2 mg/kg and fentanyl 150 μg. The ability to mask-ventilate was assessed. Ventilation was possible with an oropharyngeal airway in place. The patient was paralysed with succinylcholine 100 mg and a first attempt at intubation was made with the D-blade of the C-MAC videolaryngoscope. Because of the presence of buck teeth and loose teeth and restricted neck extension, the blade was inserted with care to prevent forceful contact of the blade with the tooth. Despite such precautionary measures taken during blade insertion, one upper incisor tooth was avulsed and was immediately retrieved. The vocal cords were visualised and intubation attempted with a size 7.0 mm ID endotracheal tube with a stylet to achieve a tube shaped like a hockey stick. The endotracheal tube hit the arytenoids and was deflected posteriorly despite optimum external laryngeal manipulation and manoeuvring by withdrawing the blade by 1 cm and lifting the handle along its axis to bring the cords in the centre of the screen. Neck flexion and rotatory movement of the tube also failed to get the tip of the tube past the cords. We decided to ventilate and reattempt with a gum elastic bougie. The second laryngoscopy revealed nothing due to bleeding from the gum at the site of avulsed tooth. We had not applied pressure to the tooth socket to stop the bleeding in our hurry to intubate and in anticipation of a successful intubation with a videolaryngoscope. Suction was immediately done. The patient had regained spontaneous ventilation by this time. Propofol 100 mg and succinylcholine 50 mg were repeated, and the blade of the videolaryngoscope was introduced in a similar manner as the first time. This time the arytenoids were poorly visible, but we managed to introduce the bougie and the endotracheal tube was successfully railroaded over it. After the black line of the endotracheal tube just crossed the glottis, the bougie was withdrawn and the cuff was inflated. Successful tracheal intubation was confirmed with a square-wave capnograph and the laryngoscope was withdrawn.

The bougie had been lubricated to facilitate railroading of the endotracheal tube. This posed difficulty because it was slipping from the hands of the person performing the intubation. Grasp of the endotracheal tube was facilitated by using a dry gauze. At no point did the patient desaturate to an SpO2 <98%. Anaesthesia was maintained with boluses of propofol and fentanyl during the intubation. The patient was successfully extubated when awake. A mild degree of postoperative sore throat was noted which improved over the next few days.

  Discussion Top

The Fourth National Audit Project from the United Kingdom reported complications of airway management in nearly three million airway interventions in the United Kingdom during a 12-month period. Difficulty had been anticipated in most of the 43 operative patients in whom the initial attempts at tracheal intubation failed. The most common problem identified was the 'failure to plan for failure'.[4] When difficulty is anticipated, airway management after induction of general anaesthesia can be justified when the risk of failure to oxygenate is low.[5] Before the advent of videolaryngoscopes, the patient safety was assigned a higher priority than comfort. Thus awake intubations were appropriate when in doubt. However, now with the availability of a variety of videolaryngoscopes and supraglottic airways (with some of the latter being used as a conduit for intubation in addition to providing ventilation and oxygenation as a rescue device), more patients can be safely managed after induction of general anaesthesia.[5] In the present case, because it was not obstructive airway pathology and rapid desaturation was unlikely with the onset of apnoea with minimal risk of aspiration after becoming unconscious and keeping in mind the primary pathology, our plan was to intubate after induction of general anaesthesia. The intubating laryngeal mask airway constituted our backup device in the event of failure to ventilate.

We also had skilled help available in terms of an experienced anaesthesiologist and neurosurgeons capable of doing an emergency tracheostomy in case of failure to secure the airway. The insertion of an oropharyngeal airway can not only be difficult in the presence of buck teeth where there is a gap between the incisors but can itself lead to avulsion of teeth. A better choice would have been the use of a nasopharyngeal airway to facilitate difficult bag and mask ventilation. A fibreoptic-aided intubation after induction of general anaesthesia could have prevented tooth injury and should have been our choice. Even minor oozing of blood should be immediately dealt with as ongoing bleeding can obscure glottic view during videolaryngoscopy. A blunt-tipped suction catheter can be introduced into the endotracheal tube with its tip protruding slightly outside the endotracheal tube. Suction can be activated with this assembly should iatrogenic bleeding hinder glottic view.[6] In our case, what came to our rescue was a gum elastic bougie despite having a percentage of glottic opening score more than 75% on videolaryngoscopy. Two cases of failed C-MAC, D-blade-assisted intubation despite optimising manoeuvres such as external laryngeal pressure, 90° counter-clockwise rotation and use of stylet were successfully intubated by channelled Airtraq laryngoscope.[7] The author fails to give a plausible explanation for this and does not mention the use of a bougie with C-MAC before switching the device. Despite a good success rate with both, there is conflicting evidence regarding which is better – the C-MAC or Airtraq. Some have reported shorter intubation time and better haemodynamic stability with C-MAC and similar number of optimisation manoeuvres with both in neutral head position.[8] Some reported the need for a significantly higher number of optimisation manoeuvres with C-MAC, whereas none were needed with Airtraq.[9] The latter was done with cervical spine immobilisation. Optimising manoeuvres included external laryngeal pressure and use of bougie in both, with sniffing position being exclusive to former and a second assistant being exclusive to the latter. Although C-MAC conventional blade and angulated D-blade have been compared predominantly in cervical spine immobilisation, there is no published case report where a failed intubation using the angulated D-blade was successful using the conventional C-MAC blade.

  Conclusion Top

There is a paucity of data regarding rescue strategies being used in cases of failed videolaryngoscope-assisted intubation. We believe that the gum elastic bougie is an essential part of the difficult airway cart. It should not lose its place of importance when compared to the newer gadgets. Both the gum elastic bougie and the videolaryngoscope should be called for simultaneously, especially to rescue an unanticipated difficult airway.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Aziz MF, Brambrink AM, Healy DW, Willett AW, Shanks A, Tremper T, et al. Success of intubation rescue techniques after failed direct laryngoscopy in adults: A Retrospective comparative analysis from the multicenter perioperative outcomes group. Anesthesiology 2016;125:656-66.  Back to cited text no. 1
Xue FS, Yang GZ, Li HX. Assessing success of rescue intubation techniques after failed direct laryngoscopy. Anesthesiology 2017;127:198-200.  Back to cited text no. 2
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 3
[PUBMED]  [Full text]  
Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth 2011;106:632-42.  Back to cited text no. 4
Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al. The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway. Can J Anaesth 2013;60:1119-38.  Back to cited text no. 5
Suzuki K, Kusunoki S, Sadamori T, Tanabe Y, Itai J, Shime N. Comparison of video and conventional laryngoscopes for simulated difficult emergency tracheal intubations in the presence of liquids in the airway. PLoS One 2019;14:e0220006.  Back to cited text no. 6
Arslan Zİ. The channelled Airtraq® as a rescue device following failed expected difficult intubation with an angulated video laryngoscope. Turk J Anaesthesiol Reanim 2018;46:399-401.  Back to cited text no. 7
Ahmed SM, Doley K, Athar M, Raza N, Siddiqi OA, Ali S. Comparison of endotracheal intubation time in neutral position between C-Mac® and Airtraq® laryngoscopes: A prospective randomised study. Indian J Anaesth 2017;61:338-43.  Back to cited text no. 8
[PUBMED]  [Full text]  
McElwain J, Laffey JG. Comparison of the C-MAC®, Airtraq®, and Macintosh laryngoscopes in patients undergoing tracheal intubation with cervical spine immobilization. Br J Anaesth 2011;107:258-64.  Back to cited text no. 9


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