Rapid Sequence Induction quickly becomes pointless if we don’t achieve first pass success. We need to maximise our chances. For that, probably the best tool we have is the bougie. The bougie works. Most studies report 10-15% increase in first pass success rates. It’s cheap and the technique is easy to learn. There is however one big problem with the bougie, a problem it shares with other tube-over-guide techniques – the arythenoid hang-up.
I hope the image on the right illustrate the problem. The space between the bougie and the tube tip becomes a ‘hook’ that snags the arythenoid.
This hang-up could be enough to convince inexperienced intubators that the tube won’t pass. In a worst-case-scenario the whole intubation attempt is abandoned which, in turn, could spell disaster.
The fix is simple. Retract the tube a centimetre or so. Then turn the tube counter-clockwise 90 degrees so that the tip and the ‘hook’ is anterior and clear of the arythenoids. Then pass the tube between the vocal cords.