D grip bougie by Dr James Ducanto

Image courtesy of Dr James DuCanto

Image courtesy of Dr James DuCanto

  1. This is my first pass technique for all intubations. DL skills still maintained: if good view, thread the needle and advance in 1 swoop. If not so good view, ELM with d-grip hand, optimize as best as possible, and hug the epiglottis until tactile tracheal ring bumps felt. This is a game changer!

  2. Thanks Derek, I am happy that you have found this to be useful. I used that setup yesterday for an urgent case that turned out to be a bowel obstruction. Yen Chow has detailed this technique on our AirwayNauts Vimeo channel.

    Loading it up this way: Cut tracheal tube package on bother ends, remove ends, lube tracheal tube cuff portion, then use extra lube to load the stylet backwards, keeping the tip of the bougie out of contact with anything else. Then pass proximal end of bougie through Murphy eye. Allow 20-22 cm of bougie protruding from tip of ETT.

    It is very fast and simple (once bougie placed) to disengage the proximal bougie portion from the Murphy eye (I do it sometimes with the fingers of my left hand that are still holding the laryngoscope handle), then grip the ETT and advance it. The tube goes in suprisingly fast if no hang ups are encountered. If a hang up occurs, withdraw the tracheal tube and turn it 90 degrees (either left or right, with the tube withdrawn from the hang-up point) before re-advancement.

    The package surrounding the tracheal tube only gets in the way (a little bit) when tracheal tube advancement takes place. Most of the time, it is not a problem, and it is a simple maneuver to advance the tube, then peel away the packaging after tube advancement.

    The potential does exist (theoretically) to deliver the tracheal tube most of the way to the larynx without having it scrape along parts of the pharnx that might have an unfavorable coating on it (like vomit). This would require advancing the tube and package together into the mouth–something I shall work out in simulation first before I advise it.

    One detail that I have never heard addressed is how to deliver a sterile and clean tracheal tube to a trachea in which the upper airway is soiled with vomit, or gastric contents (think bowel obstruction).

    • The “sterile” method you mentioned sounds extremely interesting. Do you have a video demonstrating this that I can take a look at?

      Thanks for the tip!


  3. Gave this a go this week. Works well, good tip – thanks.

    The issue (as always) is going to be making this set up a standard for trauma/septic/sick RSI in resus, when rotating nursing and doctors all have different ways of “skinning the cat”

    More and more I am incorporating these sort of pearls into routine cases, to train co-workers in FOMed pearls. A spare 10 mins during an elective case the other day to show an anaesthetic nurse who works part-time the infamous ‘Elaine Bromiley’ video lead into a 30 minute tear down of our difficult airway trolley and a spirited discussion amongst theatre staff of human factors, teamwork and future training – much better than the usual banter on Bieber!

    Little educational pearls like this are infectious. Spreading the paradigm from the usual suspects of airway enthusiasts on FOAMed to the frontline workers is the next challenge.

    It’s do-able (viz apnoeic diffusion oxygenation taken up by many ED and retrieval services as RSI SOP).

  4. I am trying to find a reference for the “D-Grip/Kiwi Grip” for my essay on optimising the first pass success rate in prehospital BAI. Anyone care to help?

    • Well….you may need to reference the PHARM website, as Yen Chow and I have not published the technique. According to my daughter (a senior in high school and one of the editors of the school newspaper), you should go to the following online resource to help you properly reference the “article”:


      Yen and I plan to meet next month at a very special simulation lab–Richard Levitan’s Cadaver Airway Course–and perhaps we can collaborate to produce a submission to an appropriate journal to document these maneuvers. I am writing a chapter on bougies for a book in the near future, so for sure, the technique will be recorded in “print” for posterity.

      Author names: James DuCanto, M.D., Yen Chow, M.D. and of course, Mihn LeCong, M.D. Just google us for our institutional titles. Let Dr. LeCong or Dr. Chow know if you need further descriptions of the PHARM website, as they are the moderators and publishers.

      • I was taught it by Paul Baker of the ANZCA difficult airway special interest group. I reckon can reference either a Pers Comm, or ref the Websites…or one of the courses. When I’ve ferenced it, I used Paul Baker, Pers Comm. you could ref Minh, Yen, Jim etc

  5. …And just to clarify the issue of how to handle the package while maintaining sterility, I now peel the package apart immediately before use, using the paper backing like a sheet of wax paper is used to remove a donut from a display case. I’m American, and I love Homer Simpson. Hmmmm…..Donuts!!!!

  6. Perfect! This is what I was going to do but just wondered if there was any published material that I could reference..

    Thank you all, much appreciated.

    Best of luck with the idea.

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