Tracheal Intubation Using the Flexible
Chapter
16 Optical Bronchoscope
P. Allan Klock, Jr, Mridula Rai and Mansukh Popat
Introduction
Flexible bronchoscopes and intubation scopes
offer unparalleled utility for the safe management
of patients with a difficult airway. Many centres
have seen decreased use of flexible optical scopes
after the introduction of videolaryngoscopes but
it is imperitive that anaesthesia providers gain
and maintain skills in using this invaluable airway
management tool. Modern flexible bronchoscopes
use a video camera at the tip of the scope rather
than glass fibres to transmit the image. The term
flexible optical bronchoscopes (FOBs) is used
here to describe devices including flexible fibre-
optic and flexible videoscopes used for tracheal
intubation.
FOBs figure prominently in most airway manage-
ment algorithms (see Chapter 4).
The FOB has many characteristics which make it
an ideal tool for tracheal intubation and some disad-
vantages that must be understood for optimal use.
Both are described in Table 16.1.
Successful FOB intubation requires several
elements:
• understanding the equipment
• learning basic manipulations and hand–eye
coordination
• mastering upper airway endoscopy
• correct tube selection
• mastering tube delivery into the trachea
The Anatomy and Function of the FOB
The modern-day FOB consists of the following parts
(Figure 16.1).
Body
This is held in the palm of either hand; the thumb
of the same hand is used to manipulate the control
140 lever and the index finger activates the suction
Table 16.1 Advantages and disadvantages of flexible optical
bronchoscopic (FOB) intubation
Advantages
Flexibility conforms easily to normal and difficult airway
anatomy
Continuous visualisation of airway during endoscopy
Less traumatic than rigid laryngoscopes:
• Does not require cervical spine movement
• Can steer around friable tissue or tumours
• Does not require significant pressure on airway structures,
facilitating intubation using topical local anaesthetics and
minimal or no sedation
Latest equipment is lightweight and portable
Can be used with other intubating techniques (e.g. direct
or videolaryngoscopy)
Can be used with ventilatory devices (e.g. supraglottic
airway (SGA))
Can be used for oral or nasal intubation
Can be used on patients of all age groups
Can be used with awake, sedated or anaesthetised patients
Can be used to determine or confirm tube position in trachea
Videoscopes facilitate teaching and assistance by other
members of the care team
Disadvantages
Equipment is expensive to purchase and maintain
Many departments find a high cost of repairs
Special skills are needed to become proficient in FOB use
Regular use is needed to maintain high skill levels
The FOB does not create space in the airway, it can only
navigate an already present pathway
The lens is easily soiled if blood, secretions or other fluids
are in the airway
The tracheal tube is not directly seen as it passes through
the vocal cords (though its position can be confirmed as
the FOB is removed)
valve. The control lever is pressed down to move
the tip of the scope anteriorly and up to move the
tip posteriorly.
With traditional fibreoptic scopes, the body has an
eyepiece, which can be focussed by a diopter ring to
produce a sharp image. The eyepiece has a pointer
which helps to orient the operator to the anterior
direction of the tip. With videoscopes the image is
projected on a video monitor. The body also has a port
which accesses the working channel.
 Chapter 15: Bougies, Stylets and Airway Exchange Catheters
Driver BE, Prekker ME, Klein LR, et al. (2018). Effect of use
of a bougie vs endotracheal tube and stylet on first-attempt
intubation success among patients with difficult airways
undergoing emergency intubation: a randomized clinical
trial. JAMA, 319, 2179–2189.
Duggan LV, Law JA, Murphy MF. (2011). Brief review:
supplementing oxygen through an airway exchange
catheter: efficacy, complications, and recommendations.
Canadian Journal of Anaesthesia, 58, 560–568.
Hodzovic I, Latto IP, Wilkes AR, Hall JE,
Mapleson WW. (2004). Evaluation of Frova,
single-use intubation introducer, in a manikin.
Comparison with Eschmann multiple-use introducer
and Portex single-use introducer. Anaesthesia, 59,
811–816.
Nolan JP, Wilson ME. (1992). An evaluation of the gum
elastic bougie. Intubation times and incidence of sore
throat. Anaesthesia, 47, 878–881.
139
Table 15.2 Airway exchange catheters

Device Material Colour Length (cm) Outer diameter Hollow DLTs Notes
Fr (mm)
Endoguide Tefloned PVC White 525/700/830 15 Fr (5) Yes Yes (size limit) Tin wire inside for
(Teleflex Medical) modelling
VBM PET Light blue 80 11/14/19 Fr Yes Yes (size limit)
Aintree intubation PET Light blue 56 19 Fr Yes (4.7 mm) No Special for FOB
catheter intubation
(Cook Medical)
AEC PET Yellow 83 8/11/14/19 Fr Yes (1.6/2.3/3/ Yes (size limit)
(Cook Medical) 3.4 mm)
Arndt AEC PET Yellow (50/65/78) (8 Fr) Yes (0.38 inch tip) Yes (size limit) Wire-guided,
(Cook Medical) 70 14 Fr bronchoscope
port
AEC soft-tip PET/soft tip Green-violet 100 11/14 Fr Yes (2.3/3 mm) Yes Stiff body/soft tip
(Cook Medical)
Tube Exchanger PET Blue 53.5/70 2/3.3/5 No Yes (size limit)
(DEAS)
Cannula AEC PET Yellow 45 8 Fr Yes No
(Cook Medical)
Tracheostomy PVC Transparent 40 6.0/7.0 mm Yes No Rounded tip with
Cannula lateral holes,
Exchange Guide depth markers
(DEAS)
Staged Extubation PET Green-violet 83 14 Fr Yes Yes 0.0135 inch/145 cm
(Cook Medical) guidewire and
soft-tipped airway
catheter

DLT, double-lumen tube; FOB, flexible optical bronchoscope; Fr, French; PET, polyethylene; PVC, polyvinyl chloride.
 Chapter 15: Bougies, Stylets and Airway Exchange Catheters
another or for management of ‘at-risk’ extubation.
While bougies may be used for the same purpose
they are generally too rigid and too short and AECs
are better suited to the role. The hollow lumen of the
AECs enables oxygen administration during or after
the procedure but this is a high-risk strategy.
Tracheal Tube Exchange
AECs are made from a range of materials (including
a combination of stiffer catheter body with a softer
distal tip intended to reduce the risk of direct trauma)
and vary in length and diameter (Table 15.2). AECs
designed for double-lumen tube exchange are longer
than those for single-lumen tubes (≈100 cm vs.
≈80 cm).
Use during ‘At-Risk’ Extubation
An AEC may be placed in the airway prior to
extubation of a patient with a difficult airway and
may be tolerated by awake patients for up to 72
hours. Local anaesthetic may be placed on the
AEC or administered through its lumen. If reintu-
bation is required the tracheal tube is railroaded
over the AEC using this as a guide. AEC-guided
reintubation success rates are ≈85% with a risk of
pneumothorax during the procedure of ≈1.5%.
This is discussed further in Chapter 21.
Optimal Use of AECs
AEC use for tube exchange or safe extubation seems
to be a safe and effective procedure if basic rules are
followed.
• Lubricate the AEC before use.
• Insert the AEC no more than 20–24 cm orally and
27–30 cm nasally in an adult patient. This ensures
the AEC sits within the tracheal tube with minimal
or no protrusion beyond the tip of the tube and it
does not reach the carina. Maintaining the AEC
tip above the carina will reduce patient discomfort
and trauma risk.
• During AEC use administer oxygen by face mask
or nasal specs. Oxygen administration through the
lumen of an AEC is associated with a significant
risk of barotrauma and should be avoided unless
there is clear benefit over standard administration
routes.
• If oxygen is administered via an AEC it should be
via a low-pressure source at low flow (≤ 1 L min−1).
• In the case of rapid decompensation of a patient
with an AEC in situ, reintubation should be
prioritised over oxygenation via the AEC.
• Use a tracheal tube with a tip designed to avoid
impingement on the airway (e.g. ILMA tracheal
tube, Parker tip tube) during railroading.
• Direct or videolaryngoscopy during intubation
over an AEC (both during tube exchange and
reintubation) is likely to facilitate the procedure
and is recommended.
• Successful reintubation over an AEC should
always be confirmed with capnography and
a backup plan should be in place for failure.
• When used for ‘at-risk’ extubation, the patient
should be nursed in high dependency or intensive
care unit and the AEC only removed when the
airway danger has resolved.
Airway Trauma Potential and Pitfalls
If used inappropriately, AECs have potential to cause
serious airway injury. Due to their length, these
devices are often inserted too far into the airway and
this risks direct airway trauma. Oxygen administra-
tion via an AEC has an even higher potential to cause
life-threatening or fatal airway injury. When the tip of
the AEC is above the carina, oxygen administration
through the AEC is unlikely to cause barotrauma
whatever the oxygen flow rates. However, when
inserted deeper into the airway to the first point of
resistance oxygen administration from a high-
pressure source (e.g. wall or cylinder) can cause bar-
otrauma within few seconds even at oxygen flow rates
as low as 2 L min−1.
Bougies, stylets and AECs are simple and highly
effective devices which when used appropriately
have an important role in managing a range of air-
way challenges, from difficult intubation to tube
exchange manoeuvres and safe extubation strategies.
Complication rates are low when used correctly, but
there is a risk of major harm if poor quality devices
are used or technique is poor. Insertion of either
device too far into the airway is the single greatest
pitfall to avoid.
Further Reading
Axe R, Middleditch A, Kelly FE, Batchelor TJ, Cook TM.
(2015). Macroscopic barotrauma caused by stiff and
soft-tipped airway exchange catheters: an in vitro case
series. Anesthesia & Analgesia, 120, 355–361. 137
 Section 1: Airway Management: Background and Techniques
(a) (b)
(c) (d) (e)
Figure 15.4 Stylets. (a) Standard malleable stylet, (b) preformed stylet for use with an angulated videolaryngoscope – inserted in tracheal
tube, (c–e) a deformable stylet: it is supplied in its ‘unactivated position’ (c), and is activated by pushing the proximal end, which causes it to
bow (d); when this is done with the stylet in the tracheal tube it curves the tube (e).
recommended. Bougie placement through an SGA with
FOB guidance has a high success rate but requires two
skilled operators. Use of an Aintree intubation catheter
is likely a preferable technique – see Chapter 13.
A bougie may also be used to aid placement of the
ProSeal LMA – this is described in Chapter 13.
Bougie Use during Emergency Front
of Neck Airway (eFONA)
A number of national airway management guidelines
promote the scalpel-bougie as a technique of choice
for eFONA (this is described in Chapter 20).
Stylets
Stylets are rigid tracheal tube guides that are inserted
into the tracheal tube before intubation. They may be
used to curve straight or non-rigid tubes and also to
accentuate the curve of curved tubes, especially during
intubation with a hyperangulated VL. Traditionally bou-
gies have been favoured in the UK and the stylet in many
other parts of the world but especially in North America.
With increased use of VLs this variation is reducing.
The major pitfall to use of a stylet is that its rigid
tip may cause significant airway injury. To avoid this
136
the distal tip of the stylet should never be inserted
further than the Murphy eye or ≈1.5 cm proximal to
the tip of the tracheal tube. The passage of the sty-
letted tube should then be observed continuously
during its passage through the airway. When the
tube tip reaches the glottis, the stylet should be pro-
gressively withdrawn as the tracheal tube is advanced,
so that the stylet tip never reaches the glottic opening.
Standard stylets are plastic-covered pieces of mal-
leable wire (Figure 15.4). Preformed, mostly rigid,
stylets are increasingly produced by individual VL
manufacturers and used during VL intubation
(Figure 15.4). The stylets are designed so that the
curve of the stylet matches the curve of the hyper-
angulated VL blade. This enables the styletted tube to
run along the distal end of the VL blade during intu-
bation, in a technique that greatly simplifies intuba-
tion (see Chapter 17).
Deformable stylets are available that can be
deployed to create a ‘dynamic’ curve such that the
curve of the tracheal tube matches that needed to
achieve intubation (Figure 15.4).
Airway Exchange Catheters (AECs)
AECs are long, narrow, semi-rigid hollow tubes,
inserted through an in-situ airway device in order to
exchange one airway device (tracheal tube or SGA) for
 Chapter 15: Bougies, Stylets and Airway Exchange Catheters

there are some concerns about cross-contamination
risk, though no data are available to support or dis-
courage their (re-)use.
Aid to Videolaryngoscope-Guided
Intubation
The advantages of videolaryngoscopy in the manage-
ment of the difficult airway are well documented, but
airway adjuncts may be needed to aid the VL-guided
intubation. Bougies or stylets may help guide the tube
into the trachea when tube advancement is proble-
matic despite a full view of the glottis, especially when
a hyperangulated VL is used. A bougie may improve
speed and success in up to one third of VL-guided
intubations and some advocate routine use especially
in emergency settings and in the pre-hospital setting.
When used with a hyperangulated blade VL the bou-
gie needs to be curved to match the blade profile
(Figure 15.3), and the degree to which this curve is
maintained during intubation will depend on the
bougie and environmental factors such as tempera-
ture. The narrow external diameter of the bougie may
improve manoeuvrability (compared with a styletted
tracheal tube) but there are also reasons why the
rigidity of a stylet may be preferred for VL-guided
intubation and this is discussed below. Stylets with
a flexible tip may provide benefit but at present are
under-evaluated (see Chapter 17).
Airway Trauma Associated with Combined
Bougie and Videolaryngoscope Use
The incidence of bougie-related airway trauma
during VL-guided intubation appears to be smaller
than during direct laryngoscopy, with a reported
incidence of 0.8% in a recent observational study
of 543 intubations using a videolaryngoscope with
the Frova bougie. The issue of the ‘blind spot’ and
trauma during intubation is discussed in Chapter
17.
Bougies for Intubation through an SGA
or for SGA Placement
Bougies have been used to aid intubation through an
SGA. Techniques include blind bougie placement or
combined with a flexible optical bronchoscope (FOB).
Blind attempts at tracheal intubation via an SGA have
very low success rates, risk airway trauma and are not

Figure 15.3 Assembling and shaping of tracheal introducers with different direct laryngoscopes (MacIntosh, Miller blade) and channelled/
unchannelled videolaryngoscopes. In each of the lower figures the bougie must be curved to match the curve of the videolaryngoscope to 135
achieve its goal.
 Section 1: Airway Management: Background and Techniques
Figure 15.2 Indications for use of tracheal introducers (bougies): note that use of bougies in Grades 3b and 4 (Cook’s modification of the
Cormack and Lehane grading) – i.e. when the epiglottis either cannot be lifted from the pharyngeal wall or is not seen at all – is unlikely to be
effective and is strongly discouraged. The top right figure illustrates the variation in shape and material of the bougies (Some images courtesy
of Giulio Frova).
the ‘hold-up’ sign is elicited during placement (see
below).
Single-use bougies with undocumented success
rate and airway trauma potential should be
avoided.
Confirming Tracheal Placement
Traditional techniques of confirming tracheal bougie
placement, when not able to see its passage into the
trachea, are ‘clicks’ (felt as the bougie tip runs against
tracheal rings) and distal ‘hold up’ (when the tip of the
bougie is wedged into the smaller bronchi). ‘Clicks’
occur in 90% and hold up in 100% of cases, making
them very reliable indicators of correct ‘blind’ tracheal
placement. However, caution is advised, especially
when single-use bougies are used. The hold-up sign
can cause serious airway trauma or bronchospasm. In
animal models, forces as small as 0.8 N (0.08 kg) can
cause airway perforation and current evidence points
against the use of this sign. Capnography after intuba-
134 tion remains the most reliable method for confirming
tracheal tube placement.
Airway Trauma and Pitfalls
A complication rate of ≈5% has been reported with
several bougies, including the Frova introducer.
Bleeding is by far the commonest complication but
epiglottic and glottic damage, tracheal and bronchial
perforation, intensive care admissions and fatalities
have been reported. A large majority of reports were
associated with the single-use bougies most likely due
to their increased stiffness.
As many available bougies have not been tested
for their airway trauma potential great caution is
needed: avoid untested devices, avoid insertion >
25 cm depth, avoid using the ‘hold-up’ sign and
avoid using a hollow lumen bougie for oxygen deliv-
ery. Keeping the laryngoscope in place throughout
airway instrumentation is also advised. Single-use
bougies should not be used with double lumen
tubes, as fragments have been found in the airway
after their use.
The reusable Eschmann bougie is designed for
a maximum of five uses. As it can only undergo low-
level decontamination and tracking uses is difficult
DEAS (DEAS) Stiff PET Light blue 53.5/70/83 2/3.3/5 Yes/2 Coudé
Vented Introducer NA Blue/yellow 47/60/75/80 5/10/14/15 Ch Yes/2 Straight/angle/
(P3) coudé
Flexible Tip (P3) Nylon + silicon tip White-yellow 66 15 Fr/5 NO Flexible/steerable tip;
phosphorus
coated (UV)
Boussignac PVC Transparent-green/ 50/60/70 NA Yes (double) Coudé 40°
(Vygon) orange
CoPilot bougie PET Orange 60 15 Fr NO Coudé
(Occam design)
Cobralet bougie PVC Orange 60 15 Fr Yes/3 Coudé/angled Preshaped/shape-
(Occam design) holding
COBRA bougie PVC – wired Orange 60→73 15 Fr NO Adjustable Wire-in-bougie to
(Occam design) change shape/
length
Pro-Breathe PVC Yellow 47/60/80 5/10/15 Fr NO Coudé Barium tip
(PROACT Medical)
Probreathe vented PVC Blue 75 14 Fr Yes/2 Curved
(PROACT Medical)
AviAir NA Orange 75/80 10/14/15 Fr Yes Coudé luminescent Luminescent tip;
(Armstrong Medical) (14 & 15 Ch) markers on left;
memory &
flexibility
Tracheal introducer PVC Blue or green 60/70/100 3.3/5 NO Coudé
(SUMI)

Fr, French; ID, inner diameter; NA, information not available; OD, outer diameter; PET, polyethylene; PTFE, polytetrafluoroethylene; PVC, polyvinyl chloride; TI, tracheal intubation; TT, tracheal
tube; UV, ultraviolet.
Table 15.1 Tracheal introducers – bougies

Device Material Colour Length (cm) OD/ID Hollow/ports Tip Notes

Fr (mm)
Eschmann (Venn) Woven polyester Golden brown 60 15 Fr (5) NO Coudé (35) 38° For TT 6.0 mm ID
GEB (inside) Memory. Reusable.
(Smiths Portex) fibreglass (outside)
ET Introducer PVC Yellow (1997) 60 15 Fr (5) < 1 mm Coudé Hollow lumen
(Smiths Portex) Azure (2006) 70 < 1 mm
Frova Intermediate Light blue 70 14 Fr (4.7) / 3 Yes (3 mm)/2 Curved 2 × 2 cm For TT 5.5 mm ID
(Cook Medical) density PET Optional stiffening
metal cannula.
Pre-curved
packaging available
Frova Polyurethane Yellow 35 8 Fr (2.7) / 2 Yes/2 Curved 1 × 1 cm For TT 3.0 mm ID
(Pediatric) Stiffening metal
cannula
VBM Stiff PET Orange 65 15 Fr (5) Yes/2 Coudé For TT 6.0 mm ID
(Coudé)
METTS PVC – metal core Light green 40/65 8/12/14 Fr NO Flexible-coudé Malleable
(VBM) For TT 6.0 mm ID
METTI PVC – plastic core Dark green 80 12/14 Fr NO Flexible-coudé For TI and TI with TT
(VBM) ID 4.5/5.5 and
larger
Pocket Introducer Stiff PET Blue 20→65 15 Fr NO Coudé Folded, to be
(VBM) extended
S-Guide PVC – partially metal White, 65 15 Fr (5) Yes/3 Coudé 35° Soft tip+ flexible +
(VBM) reinforced orange tip malleable segment
(‘airway dance’)
ET introducer Low density PET Light blue 70 10/15 Fr NO Coudé/straight
ET malleable Violet
(SunMed)
Bougie To Go Low density PET Light blue 60 15 Fr NO Coudé Rolled-up-packed
(SunMed)
Introes Pocket Special blend White 60 14 Fr (4.7) NO Flexible Double-ended use,
Bougie PTFE (Teflon) precurved
Interguide NA Green 53/70 6/10/15 Fr (2/3.3/5) NO Coudé
(Intersurgical)
Universal Stylet Low density PET + White green dots 65 15 Fr NO Coudé Hexagonal section –
Bougie metal inserts stylet & bougie
(Intersurgical) function
 Chapter 15: Bougies, Stylets and Airway Exchange Catheters
potential to improve success rates of bougie-guided
direct and VL intubation. However, they are likely to
require practice to master and to be relative rigid. It is
therefore possible they will slow down during routine
intubations and have increased risk of trauma. Their
place in airway management practice is yet to be
established.
Tips on Optimal Use
• Hold the bougie 25–30 cm from the tip as this
improves control when manoeuvring the
bougie.
• Curve the distal 20 cm of the bougie so the
curvature imitates the curvature of the airway.
This is particularly relevant with Grades 2b
(only posterior laryngeal structures visible) and
3a (only epiglottis visible). Different curves
might be needed according to the bougie used,
depending on the materials used and its shape
memory.
• A bougie can be used in Grade 1 -2a (cords visible)
views to minimise laryngoscopic traction, in order
to reduce potential airway trauma.
• Advance the bougie into the trachea no more than
20–24 cm mark at the incisor level (in adults). This
ensures the position of the bougie tip is above the
carina and is likely to significantly reduce the risk
of airway trauma.
• Load the tracheal tube over the bougie with the
tube bevel facing posteriorly in relation to the
patient. Advance it in this position. A 90°
Figure 15.1 Airway catheters overview.
A: malleable stylets; B: tracheal introducers
(bougies); C. tracheal tube guides; D:
airway exchange catheters.
anticlockwise rotation during tube advancement
may achieve the same effect but tube impingement
on the laryngeal aryepiglottic folds is more likely
during rotation.
A multicoloured bougie has been described (traffic
light bougie) which uses colours to highlight when
the safe limit of insertion depth has nearly (orange) or
has (red) been reached. This decreases over-insertion
but is not yet commercially available.
Preloading a curved bougie prior to intubation is
advocated by some users to be faster and may be
especially useful to airway managers working without
assistance. It may help awkward intubations but in
truly difficult intubations the presence of the tracheal
tube may hamper bougie manipulation.
Single-Use or Reusable Bougie?
The original Eschmann ‘gum elastic’ bougie has been
in use for more than 50 years with very few reports of
airway trauma. Some hospitals use this reusable bou-
gie as a single-use device because of cross-infection
concerns.
Some single-use bougies have been introduced
into clinical practice with little or no clinical evi-
dence of comparative performance or safety.
Success rates are generally lower than with the
Eschmann reusable bougie, with the Frova bougie
approaching equivalence. Single-use bougies are
variably stiffer and have greater airway trauma
potential, with reports of severe airway trauma.
The potential for airway trauma is increased if 131
 Tracheal Tube Introducers (Bougies), Stylets
Chapter
15 and Airway Exchange Catheters
Massimiliano Sorbello and Iljaz Hodzovic
Tracheal tube introducers (commonly referred to
as ‘bougies’), stylets and airway exchange catheters
(AECs) are widely used airway adjuncts for facil-
itating airway management in difficult circum-
stances. They are easy to use, relatively
inexpensive and have success rates of ≥ 90% in
most settings.
Bougies are 60–80 cm long narrow tubes of
4–5 mm external diameter designed to assist dur-
ing tracheal intubation. They are inserted into the
trachea during laryngoscopy and then used as
a guide over which to pass a tracheal tube (called
‘railroading the tracheal tube’). They often have
a curved or angled (‘coudé’) tip (Figure 15.1).
They are also used to aid supraglottic airway
(SGA) insertion, videolaryngoscope (VL)-guided
intubation and as adjuncts to emergency front of
neck airway (eFONA) procedures.
Stylets are rigid or semi-rigid airway adjuncts,
30–50 cm long, that are inserted into the tracheal
tube before intubation. They maintain the tracheal
tube in a particular shape and may therefore assist
during intubation (Figure 15.1).
AECs are semi-rigid hollow tubes of 80–110 cm
designed to aid airway device (SGA, and single- or
double-lumen tracheal tube) exchange or to manage
‘at-risk’ extubation (Figure 15.1).
The risk of serious airway trauma associated with
the use of bougies, stylets and AECs, and the risk of
barotrauma with the latter, invites cautious and edu-
cated use of these devices.
The usefulness of bougies and AECs is probably
underestimated and, as a consequence, under-taught,
perhaps due to the assumption that the basic techni-
ques are easy and not worthy of the meticulous dis-
130 ciplined approach they deserve.
Tracheal Tube Introducers (Bougies)
Aid to Direct Laryngoscope-Guided
Intubation
History
• 1949: Macintosh used a gum elastic urinary dilator
(bougie) to facilitate tracheal tube placement in
a patient with limited laryngeal view at
laryngoscopy with a straight blade.
• 1973: Venn introduced the ‘Eschmann
endotracheal tube introducer’, with a coudé tip and
just the right balance between stiffness and
flexibility.
• 1996: Frova designed the first hollow single-use
introducer using stiffer material.
• Current: there are numerous types of bougies
described all differing somewhat (Table 15.1).
Bougies are highly effective aids to direct laryngo-
scope-guided intubation. Reported success rate is
around 90% on first attempt rising to 94–100% with
two attempts. During unexpected difficulty success
rate is 80–90%.
Bougies are most effective when the view at direct
laryngoscopy is limited to the epiglottis only but this
can be lifted (Cook’s modified Cormack and Lehane
Grade 3a) or there is a better view but tube advance-
ment is difficult. The use of a bougie in Grades 3b
(epiglottis resting on the posterior pharyngeal wall
over the glottic opening) and 4 (only the base of the
tongue visible) is unlikely to be successful and may
lead to airway trauma due to blind attempts at tra-
cheal placement (Figure 15.2).
Bougies with a deflectable or steerable tip have
been introduced relatively recently. These have the