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Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 166-167

Frova intubating introducer – Recheck before reuse!

Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission21-Aug-2020
Date of Acceptance23-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Rakesh Kumar
Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_34_20

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How to cite this article:
Syal R, Singh N, Bhatia P, Kumar R, Jain N. Frova intubating introducer – Recheck before reuse!. Airway 2020;3:166-7

How to cite this URL:
Syal R, Singh N, Bhatia P, Kumar R, Jain N. Frova intubating introducer – Recheck before reuse!. Airway [serial online] 2020 [cited 2023 Sep 21];3:166-7. Available from: https://www.arwy.org/text.asp?2020/3/3/166/304844

Bougies and intubating introducers have become an integral part of a difficult airway cart as they aid in securing the airway during anticipated as well as unanticipated difficult intubation.[1] Use of such devices improves first-pass successful intubation.[2] We describe our experience with such a device to emphasise that despite vigilance, minor defects that develop in reused bougies may go unnoticed on visual inspection and may lead to difficulties during intubation.

A 32-year-old female (65 kg, body mass index 24.1 kg/m2) with the chief complaints of broad nasal valve with supralip depression was scheduled for septorhinoplasty. Airway examination revealed normal mouth opening with modified Mallampati Class II, normal neck extension and a thyromental distance > 6 cm. In the operation theatre, the patient was premedicated and induced with propofol, fentanyl and rocuronium. Direct laryngoscopy with Macintosh #3 blade revealed modified Cormack–Lehane Grade 3a view. A Frova intubating introducer (Cook Medical, Bloomington, Indiana, USA) was passed down the trachea up to the 25 cm mark. An attempt was made to railroad a 7.5 mm ID endotracheal tube over the intubating introducer under laryngoscopic guidance. However, resistance was encountered and the endotracheal tube could not be passed beyond the vocal cords. After trying for a few seconds, the intubating introducer was removed and bag-mask ventilation was performed for a minute. Inspection of the Frova intubating introducer revealed a deep bend exactly at 10 cm from the patient end of the intubating introducer [Figure 1] which was probably missed during the initial inspection. Hence, a new intubating introducer was called for and the patient was successfully intubated. On careful examination, it was noticed that the damaged intubating introducer was dented with the defect visible even with the stylet in place [Figure 2]. Removal of the stylet resulted in bending of the bougie, thereby obstructing passage of the endotracheal tube.
Figure 1: Bougie with a bend at 10 cm from the patient end (marked by arrow) obstructing passage of the endotracheal tube

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Figure 2: Superficial dent in the bougie with stylet in situ

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A similar case was reported by Latto et al.[3] wherein the gentle bend of the bougie during intubation caused the fracture of its outer layer at 12 cm from the distal end. Localised areas of weakness in the outer layer of a bougie due to repeated usage is the probable reason for such fractures. Though the manufacturer recommends using the device only once, some authors recommend usage up to five times.[3] In resource-poor countries, anaesthesiologists often need to reuse expensive airway equipment despite a recommendation against such action by the manufacturer. We normally use the bougie for five times after plasma sterilisation. Inappropriate storage and rough handling while managing a difficult airway are the usual causes for the development of a defect in the bougie, especially the distal 10-cm part where the stylet is absent. Hence, the lesson learnt is that when the Frova intubating introducer is reused, it should be carefully inspected, like any other airway gadget, prior to being deployed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59:675-94.  Back to cited text no. 1
Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20:71-8.  Back to cited text no. 2
Latto P. Fracture of the outer varnish layer of a gum elastic bougie. Anaesthesia 1999;54:497-8.  Back to cited text no. 3


  [Figure 1], [Figure 2]


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