Technique of insertion of gum elastic bougie , give in flow chart References - all anesthesia standard textbooks
Technique of Insertion of Gum Elastic Bougie (GEB) - Flowchart
┌─────────────────────────────────────────────────────────────────┐
│ PREPARATION (Pre-step) │
│ • Patient: Sniffing/ramped position, preoxygenated │
│ • Equipment ready: Laryngoscope, styleted ETT, GEB │
│ • GEB: Shape distal 5 cm to 60° bend (if difficult airway) │
│ • Ideally a TWO-PERSON procedure │
│ • Assistant holds both styleted ETT + GEB, ready to hand over │
└────────────────────────┬────────────────────────────────────────┘
│
▼
┌─────────────────────────────────────────────────────────────────┐
│ STEP 1: PERFORM DIRECT LARYNGOSCOPY │
│ • Insert laryngoscope (Macintosh / Miller blade) │
│ • Obtain BEST POSSIBLE view of larynx │
│ • Grade the Cormack-Lehane view │
└──────────┬──────────────────────────────────┬───────────────────┘
│ │
Grade I/II Grade III/IV
(Cords fully visible) (Only epiglottis or
│ no glottis visible)
│ │
▼ ▼
┌─────────────────────┐ ┌────────────────────────────────────┐
│ Intubate directly │ │ STEP 2: PASS GEB INTO AIRWAY │
│ with styleted ETT │ │ • Coude (angled) tip directed │
│ (no bougie needed) │ │ ANTERIORLY │
└─────────────────────┘ │ │
│ Grade II (partial cord view): │
│ → Advance through glottic opening │
│ anterior to arytenoids │
│ │
│ Grade III (epiglottis only): │
│ → Pass bougie (60° bent tip) │
│ BLINDLY under epiglottis, │
│ directed anteriorly │
└─────────────────┬──────────────────┘
│
▼
┌───────────────────────────────────────────────┐
│ STEP 3: CONFIRM TRACHEAL PLACEMENT │
│ │
│ POSITIVE signs (any of these = trachea): │
│ ✓ "Clicks" felt as coude tip rides over │
│ tracheal rings (felt in ~90% of cases) │
│ ✓ "Hold-up" / resistance felt at ~25–40 cm │
│ (bougie enters a bronchus / carina) │
│ ✓ Visible passage anterior to arytenoids │
│ ✓ Palpable neck movement felt by assistant │
│ │
│ NEGATIVE signs (= esophagus → withdraw): │
│ ✗ No clicks felt │
│ ✗ Bougie advances >40 cm without resistance │
│ (passed into stomach) │
└─────────────────┬─────────────────────────────┘
│
Confirmed in trachea?
┌──────────┴──────────┐
YES NO
│ │
│ ← Withdraw GEB
│ Reattempt
▼
┌──────────────────────────────────────────────┐
│ STEP 4: RAILROAD ETT OVER BOUGIE │
│ • Laryngoscope REMAINS IN PLACE │
│ • Assistant threads ETT over proximal end │
│ of bougie (or operator threads ETT) │
│ • Advance ETT down over bougie toward glottis│
│ • Just before entering larynx: │
│ → ROTATE ETT 90° COUNTER-CLOCKWISE │
│ (prevents tip catching on right │
│ arytenoid / anterior commissure) │
└──────────────────┬───────────────────────────┘
│
▼
┌──────────────────────────────────────────────┐
│ STEP 5: ADVANCE ETT THROUGH GLOTTIS │
│ • Advance until cuff is 2–3 cm past cords │
│ • Operator holds bougie steady throughout │
│ • Inflate cuff │
└──────────────────┬───────────────────────────┘
│
▼
┌──────────────────────────────────────────────┐
│ STEP 6: WITHDRAW LARYNGOSCOPE │
│ • Remove laryngoscope │
│ • Continue holding ETT in place │
└──────────────────┬───────────────────────────┘
│
▼
┌──────────────────────────────────────────────┐
│ STEP 7: REMOVE BOUGIE │
│ • Assistant withdraws bougie while operator │
│ holds ETT securely at lips │
└──────────────────┬───────────────────────────┘
│
▼
┌──────────────────────────────────────────────┐
│ STEP 8: CONFIRM ETT PLACEMENT │
│ • Capnography (ETCO₂) - gold standard │
│ • Bilateral equal chest rise │
│ • Equal breath sounds bilaterally │
│ • Absence of epigastric sounds │
│ • SpO₂ maintained │
│ • CXR: tip at T3-T4, 3-7 cm above carina │
└──────────────────┬───────────────────────────┘
│
▼
┌──────────────────────────────────────────────┐
│ STEP 9: SECURE THE ETT │
│ • Fix at 21-23 cm at lips (adult) │
│ • Tape / tie securely │
└──────────────────────────────────────────────┘
Key Technical Points (from standard textbooks)
- Adult curved-tip: 60 cm, 15 Fr, 40° coude tip (Eschmann/Portex)
- Adult straight: 70 cm
- Pediatric: 70 cm, 10 Fr, straight (accommodates ≥4.0 mm ETT)
- Adult version accommodates ETT ≥5.5 mm
- Clicks (coude tip striking tracheal rings) - present ~90% of cases
- Hold-up at ~25-40 cm (carina / bronchus)
- Visible passage anterior to arytenoids
References
- Roberts and Hedges' Clinical Procedures in Emergency Medicine - "Tracheal Tube Introducer (Bougie)" - detailed step-by-step two-person technique, confirmation signs, troubleshooting
- Miller's Anesthesia, 2-Volume Set, 10th Ed. - "Endotracheal Tube Introducers" (Ch. 40) and "Adjuncts to Endotracheal Intubation" - coudé tip mechanics, clicks, hold-up
- Miller's Anesthesia, 2-Volume Set, 10th Ed. - "Airway Management in Otolaryngology" (Ch. 65) - Grade II/III DL use, railroading technique
- Washington Manual of Medical Therapeutics - "Emergent Airway Adjuncts" - blind esophageal vs tracheal confirmation
- Tintinalli's Emergency Medicine: A Comprehensive Study - GEB in difficult airway algorithm and SGA conversion
- Rosen's Emergency Medicine: Concepts and Clinical Practice - bougie for ETT placement confirmation
- Scott-Brown's Otorhinolaryngology, Head and Neck Surgery, Vol. 1 - hold-up sign at 25 cm, direct laryngoscopy use
- Current Surgical Therapy, 14th Ed. - GEB specifications (60 cm, 15 Fr, 40° coude tip)
- Barash, Cullen and Stoelting's Clinical Anesthesia, 9th Ed. - bougie-guided cricothyrotomy, comparative RCT data
Give in handwritten notes for my assignment
Handwritten medical student assignment notes on ruled paper with a slight yellowish tinge, written in blue ink in neat handwriting. Title at top in bold underlined: "Gum Elastic Bougie (GEB) - Technique of Insertion". Subtitle underlined: "Page 1 of 2" Section heading (underlined, bold): "What is GEB?" - Long, semirigid introducer, 60 cm, 15 Fr (adult curved-tip) - Coude (hockey-stick) tip angled at 40° → 3.5 cm from distal end - Used to facilitate intubation when laryngeal view is suboptimal Section heading (underlined, bold): "Indications" - Cormack-Lehane Grade II, III or IV view - Anticipated / unanticipated difficult airway - Cervical spine immobilization (trauma) - Blood / vomitus obscuring view Section heading (underlined, bold): "Equipment Checklist" (with small checkbox bullets drawn) ☐ Laryngoscope (Mac / Miller blade) ☐ GEB (shaped to 60° distally if Grade III/IV) ☐ Styleted ETT (appropriate size ≥ 5.5 mm for adult) ☐ 10 mL syringe (cuff inflation) ☐ Suction ready ☐ Assistant (ideally 2-person procedure) Section heading (underlined, bold): "Step-by-Step Technique" "STEP 1 - Patient Position & Preoxygenation" → Sniffing / ramped position → 100% O₂ pre-oxygenation (3–5 min) → RSI drugs given as appropriate "STEP 2 - Perform Direct Laryngoscopy" → Insert laryngoscope, obtain BEST possible view → Grade the Cormack-Lehane view Grade I/II → vocal cords visible → intubate directly with styleted ETT Grade III/IV → only epiglottis / no glottis → proceed with GEB ↓ "STEP 3 - Shape & Introduce the GEB" → Create 60° bend in distal bougie (for Grade III/IV) → Assistant hands bougie to intubator → Coude tip directed ANTERIORLY under epiglottis → Advance gently into laryngeal inlet • Grade II: pass anterior to arytenoids into glottis • Grade III: pass blindly under epiglottis → directed anteriorly "STEP 4 - Confirm Tracheal Placement" → ✓ "CLICKS" felt — coude tip strikes tracheal rings (~90% cases) → ✓ "HOLD-UP" at 25–40 cm — bougie enters bronchus / carina → ✓ Visible passage anterior to arytenoids → ✓ Palpable neck movement (assistant feels larynx) → ✗ No clicks + bougie passes >40 cm freely = ESOPHAGUS → withdraw & retry Small margin note with arrow: "Hold-up = distal resistance when bougie hits carina/bronchus" At bottom: page number "1" in a small circle. Neat ruled lines visible throughout. Paper has slight shadow on left margin as if in a notebook.