Rev. Bras. Anestesiol. vol.66 número2

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RevBrasAnestesiol.2016;66(2):204---207

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

OfficialPublicationoftheBrazilianSocietyofAnesthesiology

www.sba.com.br

CLINICAL

INFORMATION

Use

of

a

homemade

introducer

guide

(bougie)

for

intubation

in

emergency

situation

in

patients

who

present

with

difficult

airway:

a

case

series

Felippe

Leopoldo

Dexheimer

Neto

∗

_,

_Juliana

_Mara

_Stormovski

_de

_Andrade,

Ana

Carolina

Tabajara

Raupp,

Raquel

da

Silva

Townsend,

Fernanda

Santos

Neres,

Rafael

Viegas

Cremonese

UnidadedeTerapiaIntensivaAdulto,HospitalErnestoDornelles,PortoAlegre,RS,Brazil

Received13March2013;accepted10June2013 Availableonline31March2014

KEYWORDS

Endotracheal intubation;

Airwaymanagement;

Emergencies

Abstract

Backgroundandobjectives: Theincidenceofdifficultairwayreaches10%ofemergency intu-bations.Althoughfew studiesaddresstheuseofhandmadeintroducerguidesinemergency andintensivecareenvironment,therearedescriptionsofhandmadeguidesavailableonthe Internet.Wedescribeacaseseriesontheuseofahandmadeintroducerguide(bougie) for emergencyintubationinpatientswithdifficultairway.

Casereport: Thehandmadeintroducerguidewasusedinfiveconsecutivepatientswithdifficult airways,andclinicalinstabilityandintheabsenceofanotherimmediatemethodtoobtainan airway.Thistechniqueprovidedsuccessfulintubationandtherewerenocomplications.

Conclusions:Theuseofthehandmadeintroducerguidecanbeausefuloptionforthe manage-mentofdifficultairways.

PALAVRAS-CHAVE

Intubac¸ão intratraqueal;

Manuseiodasvias

aéreas; Emergências

Empregodeguiaintrodutor(bougie)artesanalparaintubaçãoemsituaçãode emergênciaempacientesqueseapresentamcomviaaéreadedifícilintubação: sériedecasos

Resumo

Justificativaeobjetivos: A incidência de via aérea difícil chega a 10% das intubac¸ões de emergência.Aindaquepoucos estudosabordem oempregodeguiaintrodutorartesanalno ambientedeemergênciaeterapiaintensiva,hádescric¸õesdeguiasproduzidasdeforma arte-sanaldisponíveisnainternet.Nossoobjetivoédescreverumasériedecasossobreousodeum

∗_{Corresponding}_author.

E-mails:fldneto@me.com,fldneto@tj.rs.gov.br(F.L.DexheimerNeto).

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HomemadeBougie:acaseseries 205

guiaintrodutor(Bougie)artesanalparaintubac¸ãodeemergênciaempacientescomViaAérea Difícil.

Relatodecaso: Oguiaintrodutorartesanalfoiutilizadoemcincopacientesconsecutivoscom viaaéreadifícil,instabilidadeclínicaefaltadeoutrométodoimediatoparaaobtençãodeuma viaaérea.Essatécnicaproporcionousucessonaintubaçãoenãohouvecomplicações.

Conclusões: Autilizac¸ãodoguiaintrodutorartesanalpodeserumaopc¸ãoútilparaomanejo deviaaéreadifícil.

Introduction

Theinabilitytoproceedwithendotrachealintubationunder

direct visualization occursin approximately 10% of

emer-gencyintubations.Besides beinghighlyfrustratingfor the

physician,thiscomplicationincreasestherisktoapatient

whoisalreadyunstable.1

For the American Society of Anaesthesiologists, diffi-cultairwayis definedastheclinicalsituationin whichan experiencedphysicianhasdifficultywithfacemask ventila-tion,trachealintubation,orboth.2_This_difficulty_is_usually

related to poor glottic visualization during laryngoscopy, classifiedbyCormackandLehaneintoclassIIIorIV(when thedirectlaryngoscopyallowsonlytheepiglottisvision,or novisionoftheepiglottis,respectively).1,3,4

In this context, the use of an introducer guide is well documented for adult patients. It is an experience that comesmainlyfromthefieldofanaesthesiologyandthereare reportsofitsuseinemergencyandintensivecareunit(ICU) environments.1,4,5_In_addition,_there_are_recent_descriptions

of handmade production techniques of this instrument ---which can be of great value to professionals working in services with limited resources, unfortunately a frequent realityinourcountry.6

Case

series

Case1

Amale patient,14years old,in immediatepostoperative ofthoracicspinearthrodesisforseverescoliosisandhistory ofasthmadevelopedseverebronchospasmandrespiratory failure.Afterrepeatedattemptsatintubationbydifferent physicians(experiencedinairwaymanagement),andinface of an inability to visualizebeyond theepiglottis, a hand-made introducer guidewas usedat the suggestion of the anaesthetist,allowingtheintubation.

Case2

A male patient, 73 years old, in postoperative of chole-cystectomy for acute cholecystitis,was diagnosed with ---diagnosis of difficult airway by the anaesthesia team.He progressed to septic shock and acute respiratory distress syndrome.After18hoftheprocedure,therewasan acci-dental extubation. In an attempt to reintubate,only the epiglottis was visualized --- indeed, limited by abundant

secretion.Infaceofaprogressiveworseningofhypoxaemia, wechosetousethehandmadeintroducerguide,whichagain resultedinadefinitiveairway.

Case3

A female patient, 90 years old, with morbid obesity (body mass index=42), was transferred to the ICU for acuterespiratoryfailureanddecompensatedheartfailure. Laryngoscopy revealed Cormack III and ineffectiveness in ventilationwithbagandmask.Againabougiewas success-fullyused.

Case4

Amalepatient,78yearsold,withacuterenalfailureand nosocomialpneumoniadevelopedacuterespiratoryfailure. Laryngoscopy revealed Cormack III. The introducer guide wasusedtoguidetheintubation,whichallowedobtaining anuneventfuldefinitiveairway.

Case5

Afemalepatient,75yearsold,wasadmittedtotheICUfor acuteischaemicstrokewithsuddensensoriallossby haemo-rrhagictransformation of stroke. The following presented aspredictorsofdifficultairway:micrognathismandmouth openingofonly2cm.LaryngoscopyrevealedCormackIIIand thenthebougiewassuccessfullyused.

Inthesecasestherewasnoclinicalor radiological evi-denceofcomplicationsrelatedtotheuseoftheintroducer guide.Thepatientshadgoodoutcomes,beingsubsequently dischargedfromICU.

Discussion

and

conclusion

The introducer guide (described in the literature and in the market with various nomenclatures, such as Bougie, GumElasticBougie, EschmannTrachealTube Introducer®_,

Macintosh-Venn-Eschmann guide, or Frova®₎ _is _an

ancil-larydevice,consistingofsemi-rigidmaterialswhichcanbe inserted withblind technique into the airway of patients withpoor glottic visualization (Cormack-Lehane III or IV) (Fig.1).

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206 F.L.DexheimerNetoetal.

Figure1 Introducerguidemanufacturedfromthreadguide (passa-fio).

currentlyitsuseisrecommendedbyBritishanaesthetistsas thefirstoptioninthemanagementofdifficultairways.10

In aprospective study evaluatingthe use of the intro-ducerguideintheUK,itsinsertionrateatfirstattemptwas 89%andthesuccess inpassingthe endotrachealtube was 92.5%.Morerecently,7 _Shah_et_al._evaluated_its_use_in_two

emergencyphysicianstrainingcentresandthesuccessrate was 79.6% (95% confidence interval: 71.1---88%).5 _Another

clinicalstudycomparedtheuseof theintroducerguidein patientswithCormack---LehaneIIIandIV,withasuccessrate of73%,whichcanbeincreasedwiththeuseofanauxiliary mirrorinthehypopharynx,enablingindirectvisualizationof thetrachea,withasuccessrateof97%.11

Itisnoteworthythatinpatientswithsevereairway dis-tortion and inability to recognize anatomical structures, withlimitedneckmobilityorduringbrain-cardiopulmonary resuscitationmanoeuvres,theintroducerguidecanallowa properestablishmentofadefinitiveairway.12,13

Although the time needed for intubation by the guide is greater than that requiring by directlaryngoscopy, the differenceisconsideredclinicallyirrelevant.Moreover,the introducerguide canassist invarious methods of approa-ching airways, such as: exchange of endotracheal tubes, obtainingadefinitiveairwayfromlaryngealmask,and inser-tionoftwo-lumentubes,amongothers.8,14

This techniqueisconsidered safe,buttheincidenceof iatrogenicairwayinjuryanditsseverityareunknown. Condi-tionssuchasmultipleintubationattemptsinanemergency environmentandaninappropriatepositioningoftheguideor

tube areacknowledged mechanismsofiatrogenictracheal injury.15

Traumasecondarytoitsusemayoccurevenifthereisno difficultyinintubationorinmildlysymptomaticpatients.16

Generally, complications result from perforations by the guideorevenduringthepassageoftheendotrachealtube, mainly with description of lower airway injury, such as tracheallaceration,mainstembronchiinjury,haemoptysis, pneumothoraxand/orhaemothorax.

On the other hand, the bougie has the potential to introducerespiratorytractpathogens.Inastudyof contam-ination,cultureswerepositivein55% ofintroducerguides andin25%oftheirstorageplaces.17_Therefore,_it_is

emphati-callyrecommendedthesterilizationofthesetoolsbetween each use, preferably by immersionin a disinfectant solu-tionorbyformalsterilization.Eachmanufacturerspecifies amaximumnumberofre-uses,butthisrecommendationis controversial.18

For its intended use, the bougie must be introduced directlyintothetracheawiththeaidofthelaryngoscope.If thevocalcordsarenotvisible,theintroducerguideshould surpass theepiglottisinananteriordirection,maintaining the laryngoscopy. Upon entering the trachea, the opera-tor should feelcharacteristic palpable vibrations (clicks), causedbyslippageoftheintroducerguidetipincontactwith thetrachealrings.Thiseffectoccurswhentheintroducer guidetipcollideswithamainstembronchus.11,19

Once into the trachea, the laryngoscopy must be maintainedandthebougiemovedbackwardsbyafew cen-timetres. Then, an assistant must slide the endotracheal tubeovertheguide,similarlytotheSeldingertechnique.5,19

In advancing the endotracheal tube, its bevel should be posteriorly oriented --- which facilitates its insertion and avoids damageto thearytenoid cartilages.A summary of thetechniqueforuseoftheintroducerguideisavailablein

Table1.

Thebougiecanbehandmade.Todoso,arollofplastic material used in construction for introducing electricity wires in conduits should be purchased. This material can be found in electrical equipment or construction shops, underthenameofthread-guide(passa-fio)(adescriptionof its making is available in http://xa.yimg.com/kq/groups/ 1099152/952262112/name/2003+7-Guias+para+intubacao+ traqueal.pdf).

Of this material, 60---70cm, preferably with 4---5mm diameter,shouldbecut,anditsendsshouldbesandedwith acommonsandpaper(toreducetheriskofinjury). Subse-quently,oneofitsends(2.5---3cm)shouldbefolded atan angle of 40◦_, _in _the _format _of _a _hockey _stick. _This _angle

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HomemadeBougie:acaseseries 207

Table1 Protocolforintubationwithintroducerguide.

Ifthevocalcordsarevisible:

Inserttheintroducerguide; Feelpalpablevibrations(orclicks);

Inserttheendotrachealtubeovertheguide(without removingthelaryngoscope);

Rotatetheendotrachealtube90◦_clockwise_before

passingbyvocalcords(keepingthebevelofthetube posteriorlydirectedeasesitspositioningandprevents arytenoidinjury);

Removetheguide,whilemaintainingtheendotracheal tubepositioned;

Confirmproperendotrachealtubeposition.

IfthevocalcordsareNOTvisible:

Inserttheintroducerguideinamostanteriorposition possible,untilpalpableclicksarefelt;

Advancetheendotrachealtubebytheguide,tillit ‘‘locks’’orwithamaximumdistanceof45cm;

Ifnovibrations(orclicks)areperceivedoranyfeelingof resistanceafter20---40cm(the‘‘lock’’),probablythe introducerguidewillbeintheoesophagus;

Movetheguideafewcentimetresbackwardsbefore insertingtheendotrachealtube;

Rotatetheendotrachealtube90◦_clockwise_before

passingbyvocalcords(keepingthebevelofthetube posteriorlydirectedeasesitspositioningandprevents arytenoidinjury);

Removetheguide,whilemaintainingtheendotracheal tubepositioned;

Confirmproperendotrachealtubeposition.

Rememberthatwhilethelaryngoscopyandinsertionof theguideareperformed,anassistantmustbeprepared toadvancetheendotrachealtubeovertheguide (keepingitsposition).

AdaptedfromRef.4,11,andKaushal(2011).

Finally, the use of the introducer guide is a simple and cheap technique with the potential to address seri-ous problems. Furthermore, it requires little training for professionals alreadyused tointubation of trachea under direct visualization. Although the use of a bougie does not exclude other adjunct methods for airway manage-ment, its availabilityshould be considered in all hospital environments.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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