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The bougie – a cautionary study

Bougies in knots

Hi folks
this simulation study using manikins and pigs seemed to demonstrate the potential for tracheal trauma when using the holdup sign to confirm bougie is in trachea.

Bougie-related airway trauma: dangers of the hold-up sign

Whats the holdup sign you say?

Check out this paper then!

Successful difficult intubation : use of the gum elastic bougie

My service uses the single use Frova bougie described in this simulation study. I have not routinely used the holdup sign to confirm bougie is in trachea and now there is more theoretical reason for me not to!

I think better designed bougies will prevent injury, like the Introes Pocket bougie, made of Teflon and its tip is well rounded . Its also not as rigid as the Frova.

Pocket bougie

7 Comments Post a comment
  1. Yeah, I must admit I don;t use hold up as a technique w bougie…instead I feel for the gentle ‘ripple’ of tracheal rings, if at all.

    I do tend to preload my ETT nowadays, as this was a technique taught by Paul Baker (of ANZCA difficult airway SIG fame) on his difficult airway course…this means distal 15 cm or so of bougie protrudes from the preloaded ETT-bougie complex, avoiding problems of ETT in visual axis but allowing fine manipulation of the tip when held in ‘Kiwi grip’

    We too use the Frova – WITHOUT the stylet that comes pre-packed in some configurations. Throw the stylet away if you have the Frova that come with – it’s a NASTY piece of metal with sharp pointy bits.

    I keep a couple of Introes Picket Bougies in my CICO drawer on the airway trolley, as well as in prehospital pack – amazing tactile feedback, but a bit too short to do a Kiwi grip unless you are comfortable with ETT tube encroaching into visual axis

    February 23, 2014
  2. Hi Minh, good to consider caution with this sign. My only caveat is that I do find participants in simulation are much more ‘aggressive’ in their manipulation of the airway than they are in real clinical situations (I hope anyway).

    Like Tim I now preload the ETT on the Bougie (I think we use a Portex with a Coude tip – but I didn’t check the make (sorry)). Curved (Coude) tip really useful IMHO.

    Has there been much in the literature related to actual trauma rather than theoretical?

    One here but I’ve not seen many more.

    Good to consider the cautions though.



    February 23, 2014
    • thanks Simon! I am only aware of 4 case reports of bougie related trauma but prob there are more unreported.
      The Frova has a coude tip yet still was able to traumatise the porcine tracheal model in the study.
      I think it highlights that not all bougies are the least theoretically. and also it raises the issue of how we teach bougie aided ETI. just saying the holdup sign is useful is not enough when we teach it. we need to raise the safety issues..just like we would with teaching cricoid pressure ! 🙂

      February 23, 2014
  3. Minh, As I mentioned on twitter, any careful reading of this study would lead to a different interpretation. Unless you want to stop placing central lines, performing intubations, cpr, or placing chest tubes that is…

    March 5, 2014
    • fair enough, mate! its a cadaveric study and simulation method. like the title of my post..its a cautionary study,not definitive. Like the whole swine thing on SGA and carotid blood flow…it does need to be interpreted carefully as you highlight.

      having said all that, I am aware of at least 3 cases of prehospital surgical airway when the bougie holdup test failed to give any meaningful information and did not detect a failed passage of the ETT into trachea.

      I am not advocating stop using the bougie to assist surgical airway. But I am suggesting that the holdup test needs to be carefully considered if you want to use it routinely.

      March 5, 2014
      • Perhaps, I am being too vague. What the authors stated in this study is precisely analagous to saying:
        We should not perform central lines because when maximum force is applied to the needle, the needle may penetrate lung tissues.

        That is very different than our fears that, PROPER insertion of an SGA during arrest may have harmful effects.

        As I think I mentioned last time we spoke about this, your cases of failure of hold-up during ESA in a the prehospital environment were not hold-up at all. Hold-up during ESA requires advancing sufficiently to get past the sternal notch. Once past you don’t even need hold-up if you palpated the anterior surface of the posterior cricoid with your finger during dilation. At that point, simply passing the sternal notch is sufficient. We will color the bougies we use for this in future kits.

        March 5, 2014
      • ok, yes you are too vague. lets chat at SMACCGOLD then!

        March 5, 2014

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