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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 57-60

Saviour may not always be a saviour!

1 Department of Anesthesia and Intensive Care, PGIMER, Chandigarh, India
2 Department of Anesthesia and Intensive Care, GMCH-32, Chandigarh, India

Date of Submission04-Jan-2021
Date of Acceptance10-Apr-2021
Date of Web Publication29-Apr-2021

Correspondence Address:
Dr. Shalvi Mahajan
Department of Anesthesia and Intensive Care, PGIMER, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_21_21

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The intubating bougie is commonly used to railroad an endotracheal tube in anticipated or unanticipated difficult intubation. However, literature regarding bougie-induced airway trauma and complications resulting from its use is scarce. We describe a case of a 47-year-old male who suffered head injury following a road traffic accident. With deterioration of his neurological status, tracheal intubation and mechanical ventilation were planned. In view of a possible difficult airway, bougie-guided intubation was attempted. Although the airway was secured at the first attempt with a bougie-guided technique, the patient developed a pneumothorax. Later fibreoptic assessment of the tracheobronchial tree revealed a rent in the posterior wall of left main stem bronchus which was managed conservatively. This case underscores the importance of being cautious while using a bougie to secure the airway and also cautions to limit the number of airway interventions to prevent complications.

Keywords: Iatrogenic airway trauma, intubating bougie, pneumothorax

How to cite this article:
Kumar S, Mahajan S, Taneja S. Saviour may not always be a saviour!. Airway 2021;4:57-60

How to cite this URL:
Kumar S, Mahajan S, Taneja S. Saviour may not always be a saviour!. Airway [serial online] 2021 [cited 2022 Sep 26];4:57-60. Available from: https://www.arwy.org/text.asp?2021/4/1/57/315161

  Introduction Top

The intubating bougie is a simple and useful tool in the armoury of an anaesthesiologist when handling difficult airway situations. While its utility in such situations is unquestionable, its use is associated with unique problems. Yet, literature regarding bougie-associated airway trauma and other related complications is scarce. We discuss a case of difficult intubation and the problem encountered with the use of an intubating bougie during its management.

  Case Report Top

A 47-year-old obese male, a non-smoker, was admitted to our intensive care unit (ICU) with thin acute subdural haemorrhage in the left fronto-temporo-parietal region following a road traffic accident. On admission, his Glasgow Coma Score (GCS) was 14/15 (E4V4M6), with 2 mm pupils that were reacting to light. There were no associated chest, spine or long bone injuries. Conservative management was decided upon initially. However, 2 days later, following a deterioration in GCS to 8/15 (E1V2M5), tracheal intubation and mechanical ventilation were planned. As airway examination revealed a heavy jaw and short neck, a difficult airway cart was kept ready. Following preoxygenation, injection fentanyl 200 mcg, propofol 180 mg and rocuronium 60 mg were administered. Initial intubation attempt was done using Macintosh #4 laryngoscope blade. On direct laryngoscopy, arytenoids were visualised (Grade 2B by Cook's modification of Cormack-Lehane grading). After application of backward, upward and rightward pressure, the laryngoscopic grading improved to 2A. Hence, bougie-assisted intubation was planned [Figure 1]. Tracheal placement of bougie was confirmed by a ‘hold-up’ sign and a well-lubricated 7.5 mm ID endotracheal tube (ETT) was railroaded over the bougie. Endotracheal intubation was confirmed with capnography and auscultation of bilateral air entry. Mechanical ventilation was initiated (Maquet Servo ventilator) using volume control mode (tidal volume 500 mL, frequency 14 breaths per min, inspiratory: expiratory ratio 1:2 and positive end-expiratory pressure of 5 cm H2O. Fifteen minutes later, there was a fall in oxygen saturation to 82% with decreased air entry on the left side of the chest and an increase in peak airway pressure from 22 cm H2O to 40 cm H2O. FIO2 was increased to 100%. Bedside ultrasound showed a lack of lung sliding and stratosphere appearance suggestive of pneumothorax [Figure 2]a. The diagnosis of pneumothorax was confirmed simultaneously by a chest radiograph [Figure 2]b. A 28 Fr intercostal chest drain was inserted followed by a fibreoptic assessment of the tracheobronchial tree which revealed a rent in the posterior wall of the left main stem bronchus just beyond the carina which was managed conservatively. Tracheostomy was done later and the patient discharged with GCS E4VTM5.
Figure 1: Intubating bougie

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Figure 2: (a) Lung ultrasound (b) Chest X-ray

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  Discussion Top

Management of the airway in critically ill patients poses challenges to intensivists not only due to their medical condition but also due to the inaccessible and impossible assessment of conventional parameters such as Mallampati grading. Overall, the incidence of a predicted difficult airway in the ICU is around 6%.[1] Difficult Airway Guidelines support the use of an intubating bougie in laryngoscopic grades of 2A, 2B and 3A with a success rate of up to 90%.[2] In ICUs, single-use bougies are preferred to avoid cross-infection. However, being plastic coated, they are more likely to cause airway trauma.

Pneumothorax following intubation could be due to barotrauma secondary to positive pressure ventilation, rupture of bulla in a hyperinflated chest or direct airway injury. Direct airway injury is the least common cause of pneumothorax, but during management of a difficult airway, the chances of airway trauma increases dramatically from 0.5% to 7%.[3] Direct airway injury while using the intubating bougie can either occur during its insertion or during railroading of an ETT over the intubating bougie.

In our case, we believe that the intubating bougie might have gone too far into the airway, damaging the posterior wall of the left main bronchus just beyond the carina. It is possible that direct airway injury occurred due to a posteriorly directed coude tip of a single-use bougie which was advanced to a depth guided by the ‘hold-up’ sign. As the posterior wall of the trachea and bronchus are thin and unprotected with cartilage, a single-use rigid bougie has a higher propensity to cause injury.

Confirmation of tracheal placement of a bougie is commonly done using either the ‘hold-up’ sign or the appreciation of ‘clicks’ as the tip of the bougie slides over the tracheal rings. Fifteen per cent of anesthesiologists use the distal ‘hold-up’ sign for passing a bougie.[2] While using this sign, the bougie is gradually advanced into the trachea in controlled fashion till resistance (indicating arrival of the tip at the smaller airways) is felt and then the bougie is withdrawn slightly. Marson et al. published a study demonstrating force required to place a bougie within the trachea using the ‘hold-up’ sign in mannequins and the force that causes airway trauma in a porcine model.[4] The mean (standard deviation) peak force at the tip of Frova and Eschmann bougie was 5.2 (1.1) Newton and 1 (0.4) Newton respectively at all distances (25 cm, 30 cm, 45 cm and 60 cm markings), and airway perforation was seen with 1.1 (0.3) Newton and 0.9 (0.2) Newton respectively. Increased stiffness of a single-use bougie causes transmission of greater force and a higher probability of airway trauma.

Literature related to airway trauma secondary to the use of intubating bougies is sparse and limited to case reports. Few reports have described proximal airway injuries such as perforation of pharyngeal mucosa, abrasion and perforation of posterior tracheal wall, while others reported distal airway injury such as bronchial rupture.[5],[6],[7],[8] Amaniti et al. encountered tension pneumothorax following induction of anesthesia in a non-smoker otherwise healthy female posted for total thyroidectomy whose preoperative chest X-ray showed normal lung parenchyma.[9] Gangakhedkar GR et al. described pneumothorax following the use of an adult bougie in paediatric patients undergoing cervical spine surgery.[10] Pneumothorax following barotrauma or airway injury results in poor outcome in terms of death or serious brain injury. In our patient, the GCS at discharge of E4VTM5 was likely to be due to underlying traumatic brain injury.

Preventive strategies that could be followed while using a bougie include adequate lubrication of the bougie before insertion, gentle handling and stabilisation of the bougie by an assistant during the process of railroading. Using a videolaryngoscope while inserting the bougie past the vocal cords is another step that one could incorporate into one's practice. The distal ‘hold-up’ sign should not be used, and even when used, the introducer should be withdrawn a few centimetres after eliciting ‘hold-up’ sign before railroading the ETT. Even a force as minimal as 0.8 Newton can cause injury to the airway.[4] The ‘traffic light bougie’ uses a simple colouring method to prevent excessive depth of insertion. The length from 0 to 21 cm is coloured green indicating a safe depth for bougie insertion, yellow from 21 to 26 cm indicating possible contact with the carina and red from 26 cm to the end indicating a high chance of impact with the carina or distal airway structures.[11] At present, there is no consensus in literature regarding the depth of insertion of a bougie that would prevent inadvertent airway injury. However, the Difficult Airway Society guidelines recommend insertion no further than 26 cm.[12]

  Conclusion Top

Intubating bougie is one of the readily available adjuncts that helps in a difficult airway scenario. A strong clinical suspicion of complications such as a pneumothorax should always be kept in mind following its use. Avoiding using the ‘hold-up’ sign and inserting the bougie to <26 cm by prior measurement could help to avoid airway injuries. The bougie should be held loosely in the operator's fingers during advancement such that any resistance can be easily appreciated and inadvertent force will not be used to advance the bougie. It is worthwhile remembering the cardinal rules (vide supra) while using the intubating bougie which will help in preventing iatrogenic airway trauma.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

  References Top

Astin J, King EC, Bradley T, Bellchambers E, Cook TM. Survey of airway management strategies and experience of non-consultant doctors in intensive care units in the UK. Br J Anaesth 2012;109:821-5.  Back to cited text no. 1
Hodzovic I, Wilkes AR, Stacey M, Latto IP. Evaluation of clinical effectiveness of the Frova single-use tracheal tube introducer. Anaesthesia 2008;63:189-94.  Back to cited text no. 2
Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: Airway outcomes and complications. Anesthesiology 2011;114:42-8.  Back to cited text no. 3
Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: Dangers of the hold-up sign. Anaesthesia 2014;69:219-23.  Back to cited text no. 4
Kadry M, Popat M. Pharyngeal wall perforation – An unusual complication of blind intubation with a gum elastic bougie. Anaesthesia 1999;54:404-5.  Back to cited text no. 5
Arndt GA, Cambray AJ, Tomasson J. Intubation bougie dissection of tracheal mucosa and intratracheal airway obstruction. Anesth Analg 2008;107:603-4.  Back to cited text no. 6
Kalingarayar S, Nandhakumar A, Subramanian S, Namboothiri S. Airway trauma during difficult intubation… from the frying pan into the fire? Indian J Anaesth 2017;61:437-9.  Back to cited text no. 7
[PUBMED]  [Full text]  
Sahin M, Anglade D, Buchberger M, Jankowski A, Albaladejo P, Ferretti GR. Case reports: Iatrogenic bronchial rupture following the use of endotracheal tube introducers. Can J Anaesth 2012;59:963-7.  Back to cited text no. 8
Amaniti E, Provitsaki C, Papakonstantinou P, Tagarakis G, Sapalidis K, Dalakakis I, et al. Unexpected tension pneumothorax-hemothorax during induction of general anaesthesia. Hindawi Case Rep Anesthesiol 2019;Article5017082.  Back to cited text no. 9
Gangakhedkar GR, Gaur P, Shetty AN, Waghalkar PV, Dalvi AM. Pneumothorax following bougie-guided intubation in a difficult airway: A report of two cases. J Pediatr Neurosci 2019;14:154-7.  Back to cited text no. 10
[PUBMED]  [Full text]  
Paul A, Gibson AA, Robinson OD, Koch J. The traffic light bougie: A study of a novel safety modification. Anaesthesia 2014;69:214-8.  Back to cited text no. 11
Difficult Airway Society Extubation Guidelines Group, Popat M, Michelle V, Dravid R, Patel A, Swampillai C, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67:318-40.  Back to cited text no. 12


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