Inadvertent pneumothorax caused by intubating bougie.

To the Editor,

Bougie is a frequently used airway adjuvant in Cormack-Lehane 2b/3a. It is also used as an alternative to airway exchange catheter to change endotracheal tube (ETT). We report here a bougie related pneumothorax and various methods to prevent bougie induced serious airway injuries.

A 44-year-old male weighing 86 kg with thyroid swelling for 8 years was scheduled for hemithyroidectomy. Preanesthetic examination revealed short neck, prominent upper incisors and modified Mallampati grade 3. There were no features of difficult mask ventilation. After preoxygenation, anesthesia was induced with fentanyl 150 mcg and propofol 120 mg. There was no difficulty in mask ventilation and suxamethonium 100 mg was administered. The direct laryngoscopic view was CL 2b. Single use bougie-VBM Medizintechnik GmbH-Germany [Figure 1] was used to railroad 8.5 mm ETT. Pilot balloon of ETT could not be inflated as the cuff was damaged by the prominent upper incisors. Endotracheal tube was exchanged over the bougie. There was accidental distal migration of bougie as the patient bucked during rail roading. After intubation there was decreased air entry on the right side and the saturation dropped to 96%. After excluding endobronchial intubation, two possibilities were considered-either a blood clot causing right lung collapse or a pneumothorax. Flexible fiberoptic bronchoscopy done through the ETT revealed a mucosal tear in right main bronchus. A few minutes after bronchoscopic examination, systolic blood pressure dropped to 100 mmHg, airway pressure increased to 30 cm H2O and right side percussion turned into a hyper resonant note. Chest X-ray done on the operation table confirmed the clinical diagnosis of right-sided tension pneumothorax. A 28 F intercostal drain was inserted in the right fourth intercostal space. Patient was shifted to Intensive Care Unit, where he eventually made an uneventful recovery.

Figure 1

Bougie used in this case (a) compared with gum elastic bougie (b)

Bougies can be a classic gum elastic bougie or the newer single use bougies. The classic Eschmann bougie is made of braided polyester covered with resin. In contrast, the newer bougies are made of plastic, are more rigid and are either solid or hollow tubes. The distal end is not blunt as in gum elastic bougie but is a sharp circular opening to facilitate ventilation and confirm tracheal placement by EtCO2. Possible causes for airway trauma in our case were rigidity of the plastic bougie and inadvertent distal migration of the bougie during railroading of ETT. Majority of bougie related trauma were associated with single use plastic bougies as they are more rigid[1] and their distal end exerts more pressure on the tracheal wall.[2] Airway trauma can be reduced by advancing bougie under vision and following the markings as a guide to decide the depth of insertion. In case it is inserted too deep, withdraw few centimetres before railroading the tube.[3] Water based jelly should be used to facilitate smooth movement of the tube over the bougie. During railroading, the proximal end of the bougie should be stabilized by an assistant to prevent distal movement along with ETT. Finally we would like to emphasize the importance of adequate depth of anaesthesia during repeated airway manipulations.