Anesth Analg 2003;96:1845-1846
© 2003 International Anesthesia Research Society
LETTERS TO THE EDITOR
Use of Gum Elastic Bougie During Difficult Airway Management
Jae-Hyon Bahk, MD,
Ho-Geol Ryu, MD, and
Chongdoo Park, MD
Department of Anesthesiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
To the Editor:
We read with interest the article by Weisenberg et al. (1) regarding endotracheal intubation with a gum-elastic bougie (GEB) in unanticipated difficult direct laryngoscopy. The major finding of their article was that, if compared with conventional GEB use (Group 1), the failed intubation rate decreased with the aid of a dental mirror. We would like to raise a few questions concerning the article.
First, which type of GEB was used for the study? Two types of GEB are available. Only the angled one (15F x 60 cm, SIMS Portex Ltd., Hythe, UK) is useful for management of difficult airways with the kink being the GEB’s most important feature. Because of its presence, rotating the GEB’s shaft during insertion permits the tip to be "steered" around obstacles, and the GEB can be maneuvered blindly underneath the posterior surface of the epiglottis in case of the Cormack and Lehane’s grade 3 direct laryngoscopy view. On the other hand, the longer straight one (15F x 70 cm) is designed for tracheal tube exchange.
Second, were only brand-new GEBs used each time of the study? The manufacturer recommends that the GEB be reused a maximum of five times. But the tip of a used GEB may be no longer in line with the overall curvature (2), so that it may not be possible to advance the bougie behind the epiglottis. The two facts mentioned above should be clearly described because they can have a major influence on the results.
Although we admit some possibility of directing a GEB into the esophagus while railroading a tracheal tube over it, our last question is what were the possible causes of the high failure rate with false-positive signs? Contrary to their report (1), tracheal clicks and hold-up are known to be very specific and sensitive signs of the successful placement of a GEB into the trachea (3). Thus, we think that, during the insertion of a GEB for difficult airway management, both signs should be always sought without forceful insertion to excessive depths, which must be followed without delay by capnometric confirmation.
References
- Weisenberg M, Warters RD, Medalion B, et al. Endotracheal intubation with a gum-elastic bougie in unanticipated difficult direct laryngoscopy: comparison of a blind technique versus indirect laryngoscopy with a laryngeal mirror. Anesth Analg 2002; 95: 1090–3.[Abstract/Free Full Text]
- Kumar DS, Jones G. Is your bougie helping or hindering you? Anaesthesia 2001; 56: 1121.
- Kidd JF, Dyson A, Latto IP. Successful difficult intubation: use of gum-elastic bougie. Anaesthesia 1988; 43: 437–8.[Web of Science][Medline]
Response
Peter Szmuk, MD, and
Tiberiu Ezri, MD
Department of Anesthesiology, University of Texas Medical School, Houston, TX
In Response:
We would like to thank Bahk et al. for their important comments regarding our article.
We used 15F, 70-mm, brand new bougies, because the 60-mm angled-tip bougie is not available in our department (1). In our experience, the 70-mm bougie works well for both tube exchanging and for endotracheal intubation with grade III laryngoscopic views.
Reference
- Weisenberg M, Warters RD, Medalion B, et al. Endotracheal intubation with a gum-elastic bougie in unanticipated difficult direct laryngoscopy: comparison of a blind technique versus indirect laryngoscopy with a laryngeal mirror. Anesth Analg 2002; 95: 1090–3.
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