Ujuzi (Practical Pearl/Perle Pratique).

Bougie-guided digital intubation

Endotracheal intubation is a common procedure in emergency medicine with numerous adjuncts developed and utilized to manage the difficult airway. However, many of these adjuncts are expensive and may not be available either in the pre-hospital setting or in limited resource settings. Digital intubation is an alternate approach, less commonly described in the literature, 2, 3 which may be valuable when visualization of the vocal cords is limited or impossible.

In digital intubation, the practitioner uses the index and middle finger to physically elevate the epiglottis and palpate the vocal cords, guiding the endotracheal tube (ETT) between the fingers and into the trachea. Typically, the provider will use the dominant hand to palpate and guide the ETT, while the non-dominant hand assists with mouth opening, chin lift, and ETT advancement.

One of the challenges with this technique is distance from the mouth to the vocal cords, which may be increased when the patient has a long neck, small mouth opening, or all of their teeth present. Additionally, it may be challenging to fit the ETT into the vocal cords given its large size and need for constant guidance during insertion.

These challenges may be mitigated through the use of a gum elastic bougie (“bougie”) (Fig. 1). A bougie is a firm plastic ETT introducer, which is much smaller than an ETT, thereby serving as a placeholder for advancement of various sizes of ETTs into the trachea. Additionally, the rigidity and angled coude tip can facilitate advancement when the vocal cords are palpated only with the distal fingertips, which would be significantly more challenging with the highly mobile ETT. Finally, the coude tip may be advanced along the trachea to confirm placement by either palpating the tracheal rings or awaiting the “hang up” as the bougie halts at the carina.

Figure 1

Bougie-guided digital intubation technique. (A) Utilize the index and middle finger of the dominant hand to elevate the epiglottis and palpate the vocal cords. (B) Advance the bougie over index finger, guiding it through the vocal cords. (C) Advance the endotracheal tube over the bougie and through the vocal cords. (D) Remove the bougie.

It is important to be aware of several limitations with this technique. First, the patient must be adequately sedated to allow for maximal mouth opening and avoidance of hand injury. Additionally, the provider should wear an extra pair of gloves and consider adding gauze to the dorsum of the hand to prevent injury from the dentulous patient. Finally, as with all techniques for endotracheal intubation, it is important to confirm placement with multiple techniques (e.g., auscultation, capnography, bougie clicks and “hang up”).

In conclusion, bougie-guided digital intubation is a valuable technique for the provider when visualization is limited and alternate airway adjuncts are unsuccessful or unavailable.