Successful difficult intubation. Use of the gum elastic bougie.

The reliability of two signs of tracheal placement of a gum elastic bougie was studied. These signs were clicks (produced as the tip of the bougie runs over the tracheal cartilages) and hold up of the bougie as it is advanced (when the tip reaches the small bronchi). Ninety-eight simulated and two genuine Grade 3 difficult intubations were attempted with the aid of a gum elastic bougie. Seventy-eight tracheal and 22 oesophageal placements of the bougie resulted. No clicks or hold up occurred with the bougie in the oesophagus. Clicks were recorded in 89.7% of tracheal placements of the bougie. Hold up at between 24-40 cm occurred in all tracheal placements. We conclude that these signs are reliable and that they should be taught as part of any difficult intubation drill in which the gum elastic bougie is used.