What is the recommended approach for using a bougie to facilitate endotracheal (ET) intubation in pediatric patients?

From the Guidelines

The recommended approach for using a bougie to facilitate endotracheal intubation in pediatric patients involves selecting an appropriately sized bougie and inserting it with the angled tip facing anteriorly to facilitate passage through the vocal cords, as this technique has been shown to be effective in difficult airways with a high success rate of up to 100% 1. When using a bougie for pediatric endotracheal intubation, it is essential to choose the correct size, typically 5 Fr for infants and small children, and 10 Fr for older children.

• The bougie should be inserted with the angled tip facing anteriorly to facilitate passage through the vocal cords.
• After visualizing the vocal cords with direct laryngoscopy, the bougie should be gently advanced until resistance is felt at the carina or bronchi, confirming proper placement in the trachea rather than the esophagus.
• The ET tube is then threaded over the bougie while maintaining laryngoscopy, and the bougie is removed while holding the ET tube in position. The bougie offers advantages over a stylet as it is more flexible and can be used when only the epiglottis is visible (Cormack-Lehane grade 3 view) 1.
• Practitioners should be gentle during insertion to avoid trauma to delicate pediatric airway tissues, as excessive force can cause tracheal perforation or bronchial injury.
• The bougie should be well-lubricated before use, and the practitioner should maintain control of both the bougie and ET tube throughout the procedure to prevent displacement. This technique is particularly valuable in cases of anterior airways, limited mouth opening, or when standard intubation attempts have failed, with success rates ranging from 94.3% to 100% 1.

From the Research

Recommended Approach for Using a Bougie to Facilitate Endotracheal Intubation in Pediatric Patients

• The use of a bougie to facilitate endotracheal intubation in pediatric patients has been studied, with one study finding that bougie use was not associated with procedural success or complications in an academic emergency department 2.
• Another study compared the use of a bougie versus an endotracheal tube and stylet for first-attempt intubation success in patients with difficult airways, but this study was conducted in adults and found that the bougie resulted in significantly higher first-attempt intubation success 3.
• There is limited research on the use of a bougie specifically in pediatric patients, with most studies focusing on adult populations or not providing specific guidance on the use of a bougie in children 4, 5, 6.
• However, one study did assess the accuracy of using a gum elastic bougie to facilitate single lung intubation in a cadaveric model, finding that bougie-guided single lung intubation was highly accurate for both left and right mainstem intubations 6.

Key Considerations

• The decision to use a bougie to facilitate endotracheal intubation in pediatric patients should be based on individual patient factors and the clinical judgment of the healthcare provider.
• Further research is needed to determine the effectiveness and safety of bougie use in pediatric patients, particularly in emergency settings.
• Healthcare providers should be aware of the potential benefits and limitations of bougie use in pediatric patients and be trained in the proper technique for using a bougie to facilitate endotracheal intubation 2.