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.┬áThe 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.

This entry was posted in Airway management, Anesthesia, Emergency Medicine, Intensive Care. Bookmark the permalink.


  1. Big fan of the ‘flip-flop’ manoeuvre…does it need an eponymous name?

    Those Parker tip ETTs are also really nifty, especially if doing a fibreoptic thro iLMA or playing around with some of the VLs

  2. Christopher says:

    Dr. Levitan offered a simple way to remember this during his airway course: “inLet Left”.

    And the companion to this is “Rings Right,” if you encounter hang-up on the tracheal rings, when using a stylette angle greater than 30 degrees.

  3. Nah, I’ve already got an eponymous sign

    If you put the end of a biro in your bellybutton and twist it, you get a weird tingling along the dorsum of your penis (if you are male, I have no idea what happens if you are female and the wife refuses to let me experiment on her)

    This is the ‘Leeuwenburg sign’

    Of course, there may well be a reverse-Leeuwenburg sign…I need to find someone to help me with that…

  4. Pingback: Gameshow or Desert Island Supraglottic Airway Devices? - KI Doc

Leave a Reply

Your email address will not be published. Required fields are marked *