Tracheal Intubation Using the Flexible

Chapter

16 Optical Bronchoscope
P. Allan Klock, Jr, Mridula Rai and Mansukh Popat

Introduction Table 16.1 Advantages and disadvantages of flexible optical

bronchoscopic (FOB) intubation
Flexible bronchoscopes and intubation scopes Advantages
offer unparalleled utility for the safe management Flexibility conforms easily to normal and difficult airway
of patients with a difficult airway. Many centres anatomy
have seen decreased use of flexible optical scopes Continuous visualisation of airway during endoscopy
Less traumatic than rigid laryngoscopes:
after the introduction of videolaryngoscopes but
• Does not require cervical spine movement
it is imperitive that anaesthesia providers gain • Can steer around friable tissue or tumours
and maintain skills in using this invaluable airway • Does not require significant pressure on airway structures,
management tool. Modern flexible bronchoscopes facilitating intubation using topical local anaesthetics and
use a video camera at the tip of the scope rather minimal or no sedation
than glass fibres to transmit the image. The term Latest equipment is lightweight and portable
Can be used with other intubating techniques (e.g. direct
flexible optical bronchoscopes (FOBs) is used or videolaryngoscopy)
here to describe devices including flexible fibre- Can be used with ventilatory devices (e.g. supraglottic
optic and flexible videoscopes used for tracheal airway (SGA))
Can be used for oral or nasal intubation
intubation. Can be used on patients of all age groups
FOBs figure prominently in most airway manage- Can be used with awake, sedated or anaesthetised patients
ment algorithms (see Chapter 4). Can be used to determine or confirm tube position in trachea
Videoscopes facilitate teaching and assistance by other
The FOB has many characteristics which make it members of the care team
an ideal tool for tracheal intubation and some disad- Disadvantages
vantages that must be understood for optimal use. Equipment is expensive to purchase and maintain
Both are described in Table 16.1. Many departments find a high cost of repairs
Special skills are needed to become proficient in FOB use
Successful FOB intubation requires several Regular use is needed to maintain high skill levels
elements: The FOB does not create space in the airway, it can only
navigate an already present pathway
• understanding the equipment
The lens is easily soiled if blood, secretions or other fluids
• learning basic manipulations and hand–eye are in the airway
coordination The tracheal tube is not directly seen as it passes through
the vocal cords (though its position can be confirmed as
• mastering upper airway endoscopy the FOB is removed)
• correct tube selection
• mastering tube delivery into the trachea
valve. The control lever is pressed down to move
The Anatomy and Function of the FOB the tip of the scope anteriorly and up to move the
tip posteriorly.
The modern-day FOB consists of the following parts
With traditional fibreoptic scopes, the body has an
(Figure 16.1).
eyepiece, which can be focussed by a diopter ring to
produce a sharp image. The eyepiece has a pointer
Body which helps to orient the operator to the anterior
This is held in the palm of either hand; the thumb direction of the tip. With videoscopes the image is
of the same hand is used to manipulate the control projected on a video monitor. The body also has a port
140 lever and the index finger activates the suction 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 Hodzovic I, Latto IP, Wilkes AR, Hall JE,
of a bougie vs endotracheal tube and stylet on first-attempt Mapleson WW. (2004). Evaluation of Frova,
intubation success among patients with difficult airways single-use intubation introducer, in a manikin.
undergoing emergency intubation: a randomized clinical Comparison with Eschmann multiple-use introducer
trial. JAMA, 319, 2179–2189. and Portex single-use introducer. Anaesthesia, 59,
Duggan LV, Law JA, Murphy MF. (2011). Brief review: 811–816.
supplementing oxygen through an airway exchange Nolan JP, Wilson ME. (1992). An evaluation of the gum
catheter: efficacy, complications, and recommendations. elastic bougie. Intubation times and incidence of sore
Canadian Journal of Anaesthesia, 58, 560–568. 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. • In the case of rapid decompensation of a patient
While bougies may be used for the same purpose with an AEC in situ, reintubation should be
they are generally too rigid and too short and AECs prioritised over oxygenation via the AEC.
are better suited to the role. The hollow lumen of the • Use a tracheal tube with a tip designed to avoid
AECs enables oxygen administration during or after impingement on the airway (e.g. ILMA tracheal
the procedure but this is a high-risk strategy. tube, Parker tip tube) during railroading.
• Direct or videolaryngoscopy during intubation
Tracheal Tube Exchange over an AEC (both during tube exchange and
AECs are made from a range of materials (including reintubation) is likely to facilitate the procedure
a combination of stiffer catheter body with a softer and is recommended.
distal tip intended to reduce the risk of direct trauma) • Successful reintubation over an AEC should
and vary in length and diameter (Table 15.2). AECs always be confirmed with capnography and
designed for double-lumen tube exchange are longer a backup plan should be in place for failure.
than those for single-lumen tubes (≈100 cm vs. • When used for ‘at-risk’ extubation, the patient
≈80 cm). should be nursed in high dependency or intensive
care unit and the AEC only removed when the
airway danger has resolved.
Use during ‘At-Risk’ Extubation
An AEC may be placed in the airway prior to
extubation of a patient with a difficult airway and
Airway Trauma Potential and Pitfalls
If used inappropriately, AECs have potential to cause
may be tolerated by awake patients for up to 72
serious airway injury. Due to their length, these
hours. Local anaesthetic may be placed on the
devices are often inserted too far into the airway and
AEC or administered through its lumen. If reintu-
this risks direct airway trauma. Oxygen administra-
bation is required the tracheal tube is railroaded
tion via an AEC has an even higher potential to cause
over the AEC using this as a guide. AEC-guided
life-threatening or fatal airway injury. When the tip of
reintubation success rates are ≈85% with a risk of
the AEC is above the carina, oxygen administration
pneumothorax during the procedure of ≈1.5%.
through the AEC is unlikely to cause barotrauma
This is discussed further in Chapter 21.
whatever the oxygen flow rates. However, when
inserted deeper into the airway to the first point of
Optimal Use of AECs resistance oxygen administration from a high-
AEC use for tube exchange or safe extubation seems pressure source (e.g. wall or cylinder) can cause bar-
to be a safe and effective procedure if basic rules are otrauma within few seconds even at oxygen flow rates
followed. as low as 2 L min−1.
• Lubricate the AEC before use. Bougies, stylets and AECs are simple and highly
• Insert the AEC no more than 20–24 cm orally and
effective devices which when used appropriately
27–30 cm nasally in an adult patient. This ensures have an important role in managing a range of air-
the AEC sits within the tracheal tube with minimal way challenges, from difficult intubation to tube
or no protrusion beyond the tip of the tube and it exchange manoeuvres and safe extubation strategies.
does not reach the carina. Maintaining the AEC Complication rates are low when used correctly, but
tip above the carina will reduce patient discomfort there is a risk of major harm if poor quality devices
and trauma risk. are used or technique is poor. Insertion of either
device too far into the airway is the single greatest
• During AEC use administer oxygen by face mask
pitfall to avoid.
or nasal specs. Oxygen administration through the
lumen of an AEC is associated with a significant
risk of barotrauma and should be avoided unless Further Reading
there is clear benefit over standard administration Axe R, Middleditch A, Kelly FE, Batchelor TJ, Cook TM.
routes. (2015). Macroscopic barotrauma caused by stiff and
• If oxygen is administered via an AEC it should be soft-tipped airway exchange catheters: an in vitro case
via a low-pressure source at low flow (≤ 1 L min−1). 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 further than the Murphy eye or ≈1.5 cm proximal to
FOB guidance has a high success rate but requires two the tip of the tracheal tube. The passage of the sty-
skilled operators. Use of an Aintree intubation catheter letted tube should then be observed continuously
is likely a preferable technique – see Chapter 13. during its passage through the airway. When the
A bougie may also be used to aid placement of the tube tip reaches the glottis, the stylet should be pro-
ProSeal LMA – this is described in Chapter 13. 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-
Bougie Use during Emergency Front leable wire (Figure 15.4). Preformed, mostly rigid,
of Neck Airway (eFONA) stylets are increasingly produced by individual VL
A number of national airway management guidelines manufacturers and used during VL intubation
promote the scalpel-bougie as a technique of choice (Figure 15.4). The stylets are designed so that the
for eFONA (this is described in Chapter 20). 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-
Stylets bation, in a technique that greatly simplifies intuba-
Stylets are rigid tracheal tube guides that are inserted tion (see Chapter 17).
into the tracheal tube before intubation. They may be Deformable stylets are available that can be
used to curve straight or non-rigid tubes and also to deployed to create a ‘dynamic’ curve such that the
accentuate the curve of curved tubes, especially during curve of the tracheal tube matches that needed to
intubation with a hyperangulated VL. Traditionally bou- achieve intubation (Figure 15.4).
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. Airway Exchange Catheters (AECs)
The major pitfall to use of a stylet is that its rigid AECs are long, narrow, semi-rigid hollow tubes,
tip may cause significant airway injury. To avoid this inserted through an in-situ airway device in order to
136
the distal tip of the stylet should never be inserted exchange one airway device (tracheal tube or SGA) for
 Chapter 15: Bougies, Stylets and Airway Exchange Catheters

there are some concerns about cross-contamination rigidity of a stylet may be preferred for VL-guided
risk, though no data are available to support or dis- intubation and this is discussed below. Stylets with
courage their (re-)use. a flexible tip may provide benefit but at present are
under-evaluated (see Chapter 17).
Aid to Videolaryngoscope-Guided
Intubation Airway Trauma Associated with Combined
The advantages of videolaryngoscopy in the manage- Bougie and Videolaryngoscope Use
ment of the difficult airway are well documented, but The incidence of bougie-related airway trauma
airway adjuncts may be needed to aid the VL-guided during VL-guided intubation appears to be smaller
intubation. Bougies or stylets may help guide the tube than during direct laryngoscopy, with a reported
into the trachea when tube advancement is proble- incidence of 0.8% in a recent observational study
matic despite a full view of the glottis, especially when of 543 intubations using a videolaryngoscope with
a hyperangulated VL is used. A bougie may improve the Frova bougie. The issue of the ‘blind spot’ and
speed and success in up to one third of VL-guided trauma during intubation is discussed in Chapter
intubations and some advocate routine use especially 17.
in emergency settings and in the pre-hospital setting.
When used with a hyperangulated blade VL the bou- Bougies for Intubation through an SGA
gie needs to be curved to match the blade profile
(Figure 15.3), and the degree to which this curve is or for SGA Placement
maintained during intubation will depend on the Bougies have been used to aid intubation through an
bougie and environmental factors such as tempera- SGA. Techniques include blind bougie placement or
ture. The narrow external diameter of the bougie may combined with a flexible optical bronchoscope (FOB).
improve manoeuvrability (compared with a styletted Blind attempts at tracheal intubation via an SGA have
tracheal tube) but there are also reasons why the 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).
Airway Trauma and Pitfalls
A complication rate of ≈5% has been reported with
Single-use bougies with undocumented success
several bougies, including the Frova introducer.
rate and airway trauma potential should be
Bleeding is by far the commonest complication but
avoided.
epiglottic and glottic damage, tracheal and bronchial
perforation, intensive care admissions and fatalities
Confirming Tracheal Placement have been reported. A large majority of reports were
Traditional techniques of confirming tracheal bougie associated with the single-use bougies most likely due
placement, when not able to see its passage into the to their increased stiffness.
trachea, are ‘clicks’ (felt as the bougie tip runs against As many available bougies have not been tested
tracheal rings) and distal ‘hold up’ (when the tip of the for their airway trauma potential great caution is
bougie is wedged into the smaller bronchi). ‘Clicks’ needed: avoid untested devices, avoid insertion >
occur in 90% and hold up in 100% of cases, making 25 cm depth, avoid using the ‘hold-up’ sign and
them very reliable indicators of correct ‘blind’ tracheal avoid using a hollow lumen bougie for oxygen deliv-
placement. However, caution is advised, especially ery. Keeping the laryngoscope in place throughout
when single-use bougies are used. The hold-up sign airway instrumentation is also advised. Single-use
can cause serious airway trauma or bronchospasm. In bougies should not be used with double lumen
animal models, forces as small as 0.8 N (0.08 kg) can tubes, as fragments have been found in the airway
cause airway perforation and current evidence points after their use.
against the use of this sign. Capnography after intuba- The reusable Eschmann bougie is designed for
134 tion remains the most reliable method for confirming a maximum of five uses. As it can only undergo low-
tracheal tube placement. 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

Figure 15.1 Airway catheters overview.

A: malleable stylets; B: tracheal introducers
(bougies); C. tracheal tube guides; D:
airway exchange catheters.

potential to improve success rates of bougie-guided anticlockwise rotation during tube advancement
direct and VL intubation. However, they are likely to may achieve the same effect but tube impingement
require practice to master and to be relative rigid. It is on the laryngeal aryepiglottic folds is more likely
therefore possible they will slow down during routine during rotation.
intubations and have increased risk of trauma. Their A multicoloured bougie has been described (traffic
place in airway management practice is yet to be light bougie) which uses colours to highlight when
established. the safe limit of insertion depth has nearly (orange) or
has (red) been reached. This decreases over-insertion
Tips on Optimal Use but is not yet commercially available.
Preloading a curved bougie prior to intubation is
• Hold the bougie 25–30 cm from the tip as this
advocated by some users to be faster and may be
improves control when manoeuvring the
especially useful to airway managers working without
bougie.
assistance. It may help awkward intubations but in
• Curve the distal 20 cm of the bougie so the truly difficult intubations the presence of the tracheal
curvature imitates the curvature of the airway. tube may hamper bougie manipulation.
This is particularly relevant with Grades 2b
(only posterior laryngeal structures visible) and
3a (only epiglottis visible). Different curves Single-Use or Reusable Bougie?
might be needed according to the bougie used, The original Eschmann ‘gum elastic’ bougie has been
depending on the materials used and its shape in use for more than 50 years with very few reports of
memory. airway trauma. Some hospitals use this reusable bou-
• A bougie can be used in Grade 1 -2a (cords visible) gie as a single-use device because of cross-infection
views to minimise laryngoscopic traction, in order concerns.
to reduce potential airway trauma. Some single-use bougies have been introduced
• Advance the bougie into the trachea no more than into clinical practice with little or no clinical evi-
20–24 cm mark at the incisor level (in adults). This dence of comparative performance or safety.
ensures the position of the bougie tip is above the Success rates are generally lower than with the
carina and is likely to significantly reduce the risk Eschmann reusable bougie, with the Frova bougie
of airway trauma. approaching equivalence. Single-use bougies are
• Load the tracheal tube over the bougie with the variably stiffer and have greater airway trauma
tube bevel facing posteriorly in relation to the potential, with reports of severe airway trauma.
patient. Advance it in this position. A 90° 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 Tracheal Tube Introducers (Bougies)

as ‘bougies’), stylets and airway exchange catheters
(AECs) are widely used airway adjuncts for facil-
itating airway management in difficult circum-
Aid to Direct Laryngoscope-Guided
stances. They are easy to use, relatively Intubation
inexpensive and have success rates of ≥ 90% in History
most settings.
• 1949: Macintosh used a gum elastic urinary dilator
Bougies are 60–80 cm long narrow tubes of
(bougie) to facilitate tracheal tube placement in
4–5 mm external diameter designed to assist dur-
a patient with limited laryngeal view at
ing tracheal intubation. They are inserted into the
laryngoscopy with a straight blade.
trachea during laryngoscopy and then used as
• 1973: Venn introduced the ‘Eschmann
a guide over which to pass a tracheal tube (called
‘railroading the tracheal tube’). They often have endotracheal tube introducer’, with a coudé tip and
a curved or angled (‘coudé’) tip (Figure 15.1). just the right balance between stiffness and
They are also used to aid supraglottic airway flexibility.
(SGA) insertion, videolaryngoscope (VL)-guided • 1996: Frova designed the first hollow single-use
intubation and as adjuncts to emergency front of introducer using stiffer material.
neck airway (eFONA) procedures. • Current: there are numerous types of bougies
Stylets are rigid or semi-rigid airway adjuncts, described all differing somewhat (Table 15.1).
30–50 cm long, that are inserted into the tracheal Bougies are highly effective aids to direct laryngo-
tube before intubation. They maintain the tracheal scope-guided intubation. Reported success rate is
tube in a particular shape and may therefore assist around 90% on first attempt rising to 94–100% with
during intubation (Figure 15.1). two attempts. During unexpected difficulty success
AECs are semi-rigid hollow tubes of 80–110 cm rate is 80–90%.
designed to aid airway device (SGA, and single- or Bougies are most effective when the view at direct
double-lumen tracheal tube) exchange or to manage laryngoscopy is limited to the epiglottis only but this
‘at-risk’ extubation (Figure 15.1). can be lifted (Cook’s modified Cormack and Lehane
The risk of serious airway trauma associated with Grade 3a) or there is a better view but tube advance-
the use of bougies, stylets and AECs, and the risk of ment is difficult. The use of a bougie in Grades 3b
barotrauma with the latter, invites cautious and edu- (epiglottis resting on the posterior pharyngeal wall
cated use of these devices. over the glottic opening) and 4 (only the base of the
The usefulness of bougies and AECs is probably tongue visible) is unlikely to be successful and may
underestimated and, as a consequence, under-taught, lead to airway trauma due to blind attempts at tra-
perhaps due to the assumption that the basic techni- cheal placement (Figure 15.2).
ques are easy and not worthy of the meticulous dis- Bougies with a deflectable or steerable tip have
130 ciplined approach they deserve. been introduced relatively recently. These have the