15/07/2019 Endotracheal tube introducers (gum elastic bougie) for emergency intubation - UpToDate

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Endotracheal tube introducers (gum elastic bougie) for

emergency intubation
Author: Erik G Laurin, MD, FAAEM
Section Editor: Allan B Wolfson, MD
Deputy Editor: Jonathan Grayzel, MD, FAAEM

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jun 2019. | This topic last updated: May 09, 2019.

INTRODUCTION

The endotracheal tube introducer (ETI) is an effective and inexpensive adjunct to difficult airway
management that is easy to use. We recommend that an ETI be readily available in every
emergency department.

This topic will review the types of ETIs, indications and contraindications for their use, proper
technique for using the devices during emergency tracheal intubation, and evidence of their
effectiveness. Other airway devices and aspects of emergency airway management are discussed
separately. (See "Devices for difficult emergency airway management in adults outside the
operating room" and "Advanced emergency airway management in adults" and "Rapid sequence
intubation for adults outside the operating room" and "Emergency airway management in children:
Unique pediatric considerations".)

TERMINOLOGY AND EQUIPMENT

Several terms are used to describe the classic endotracheal tube introducer (ETI). Although the
phrase "gum elastic bougie" is common, we find it confusing since the ETI is neither gum nor
elastic and is not used as a bougie (ie, dilator). In this topic, we will refer to the device as an
endotracheal or tracheal tube introducer.

The ETI consists of a 60 cm stylet with the distal tip bent at a 30 degree angle. The bend allows
the intubator to direct the tip anteriorly under the epiglottis and through the vocal cords, which may
not be visible.

Dimensions and use are comparable among the three main types of ETI available:
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● Eschmann Introducer – Woven Dacron rod with resin coating, can be sterilized and reused.
This is commonly referred to as a "gum elastic bougie" (picture 1)

● SunMed/Flex Guide – Solid polyethylene, single use (picture 2 and picture 3)

● Frova – Hollow, single-use plastic introducer with fenestrated tip to allow oxygenation;
includes 15 mm adapter for standard bag-valve assembly (picture 4)

Although the Eschmann introducer is more expensive, it can be used multiple times, so the
average cost per intubation is comparable to that of a single use introducer. Nevertheless, some
clinicians prefer single use introducers because multiple use introducers are sometimes
inadvertently thrown away. The plastic of the SunMed stylet has "memory" so J-shaped anterior
curvatures can be maintained for use with video devices. (See "Devices for difficult emergency
airway management in adults outside the operating room", section on 'Advanced laryngoscopes'.)

INDICATIONS

The endotracheal tube introducer (ETI) is a useful tool for intubation when the epiglottis is visible,
but the vocal cords cannot be seen (Grade III Cormack-Lehane view) [1]. The ETI can be used in
conjunction with standard laryngoscopes, video laryngoscopes, and fiberoptic intubation devices.

Historically, the ETI was used only when an incomplete view of the glottis was obtained. However,
research suggests that use of an ETI increases first-pass success rates even when video
laryngoscopes (VLs) are used [2]. This may be due to improved visibility. As the ballooned end of
the tracheal tube passes in front of the camera lens at the tip of the VL blade, the clinician may
temporarily lose sight of the glottis. The line of sight is not lost when an ETI is placed, enabling
more secure subsequent placement of the tracheal tube. The small size of the ETI relative to
typical tracheal tubes may also be a factor, as anatomic distortion is less likely to create an
obstacle to placement of an ETI.

CONTRAINDICATIONS AND PRECAUTIONS

An endotracheal tube introducer (ETI) should be used with caution if at all when there is possible
laryngeal or tracheal injury. In such cases the ETI may exacerbate the injury or be advanced
outside the airway into adjacent structures. An ETI is unlikely to be beneficial when no part of the
airway can be seen (Grade IV Cormack-Lehane view).

PREPARATION

Lubrication may be applied to the endotracheal tube introducer (ETI) if the endotracheal tube is a
tight fit. Lubricant allows the endotracheal tube to pass over the ETI more easily. If the fit is not
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tight, lubricant can make the ETI difficult to grasp and control.

TECHNIQUE

Placement of the endotracheal tube introducer (ETI) and the subsequent advancement of the
tracheal tube over it are performed as described here. A video clip demonstrating the technique is
provided (movie 1).

● Identify the epiglottis. External laryngeal manipulation (picture 5) or other positioning

techniques may be needed to find the epiglottis (figure 1 and picture 6 and picture 7),
depending upon the device being used for laryngoscopy and the clinical scenario.

● Place the ETI. Advance the ETI, with its tip pointing anteriorly and under the epiglottis, into
the trachea. When advancing the ETI, be sure to maintain the tip in the midline with its anterior
orientation (do not allow it to rotate to either side); if it rotates significantly, the anteriorly
located tracheal rings may not be appreciated. Care must be taken to avoid forceful insertion
as this can cause injury (ie, bleeding or perforation).

● Confirm placement of the ETI. Two tactile sensations suggest correct placement in the
trachea [1,3]. One sign is the feeling of vibrations or "clicks" as the tip of the ETI is advanced
over the tracheal rings. However, it is important to remember that the angled tip of the ETI
must be oriented anteriorly for the tip to encounter the rings.

Another sign is resistance to further insertion. As the introducer advances to between 24 and
40 cm from the teeth, the distal tip becomes lodged in smaller airways and cannot advance.
This is sometimes referred to as the "stop sign" or "hard stop." In contrast, if the ETI is in the
esophagus, the tracheal rings cannot be felt and the introducer advances easily into the
stomach, far past the 40 cm mark where the "stop sign" would normally occur if the ETI were
in the tracheobronchial tree.

When advancing the ETI, avoid applying too much pressure if resistance is encountered.
Excessive force can traumatize the airway [4]. In addition, it may be helpful to withdraw the
introducer several centimeters before railroading the endotracheal tube over the introducer
(next step in the technique) to avoid forceful advancement.

● Place the endotracheal tube (ETT). Once the ETI is in the trachea, place the distal end of
the ETT over the free end of the ETI and advance it using a Seldinger-like technique. This
generally requires an assistant to place the ETT on the proximal end of the introducer.
Advance the ETT over the introducer into the trachea, while keeping the laryngoscope in
place.

● Withdraw the ETI. Once the ETT is advanced the appropriate distance, withdraw the
introducer.
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● Confirm that the ETT is in the trachea. Confirmation proceeds as usual and we recommend
the use of an end-tidal CO2 detector.

The following tips may facilitate placement of the ETT over the introducer:

● Throughout the procedure, the operator should maintain proper position of the laryngoscope
with the left hand. The tendency is to remove the laryngoscope after the introducer is in the
trachea, but doing so allows the tongue to fall posteriorly and potentially hinder tube passage.

● Passage of the ETT is easier if it is close in size to the introducer. The greater the disparity,
the more likely the ETT will have an overhanging leading edge that can catch on the
arytenoids or aryepiglottic folds during insertion. This may require using a smaller ETT than
would otherwise be used, but this is a small price to pay for success in a difficult situation.

● If the ETT impinges on the arytenoids, slight withdrawal of the ETT (to disengage the tip from
the arytenoids), followed by careful counterclockwise rotation and relaxation of cricoid
pressure (if used) may facilitate passage. A video clip demonstrating the technique is provided
(movie 2).

PEDIATRIC CONSIDERATIONS

The techniques described above can be used in children. Pediatric-sized endotracheal tube
introducers (ETIs) are as small as 10 French and can accommodate an endotracheal tube (ETT)
as small as 5 mm.

EVIDENCE OF EFFECTIVENESS

Evidence suggests that endotracheal tube introducers (ETIs) are associated with improved
procedural success for patients undergoing elective and emergency intubation, especially those
with impaired glottic views or characteristics that suggest a difficult airway [1,2,5-8]. As an
example, in a trial of over 750 adults undergoing emergency intubation, the use of an ETI during
direct laryngoscopy by experienced physicians resulted in a higher first-pass success rate when
compared to the use of a styletted endotracheal tube in all patients (98 versus 87 percent,
respectively) and in patients who had at least one characteristic of a difficult airway such as
obesity, short neck, small mandible, large tongue, need for cervical spine immobilization, airway
obstruction or edema, secretions obstructing the glottic view, or facial trauma (96 versus 82
percent, respectively) [2].

Little training is needed before introducers can be used successfully [9-11]. This is likely because
of the similarity to standard intubating technique and familiarity with the Seldinger method. In an

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observational study of prehospital airway management, physicians used an ETI to intubate 78

percent of difficult airways in which standard techniques had failed [11].

COMPLICATIONS

Complications from airway introducers are rare and involve mechanical trauma to airway structures
[12]. Excessive force while advancing the endotracheal tube introducer (ETI) or the endotracheal
tube (ETT) might damage the larynx, trachea, or branches of the airway [4]. The endotracheal tube
might catch on the arytenoids during placement and impede advancement. Forceful advancement
can then dislocate the arytenoid cartilage or cause other trauma to the airway.

OTHER USES

Additional uses of endotracheal tube introducers (ETIs) include the following:

● Means for distinguishing tracheal from esophageal endotracheal tube (ETT) placement.
This approach has been advocated in cardiac arrest patients, where end-tidal CO2 may not be
measurable. However, there is insufficient evidence to recommend that introducers be relied
upon as the sole indicator of proper ETT placement [3,13]. In a study using 20 human
cadavers, clinicians without prior experience using an ETI were able, using the techniques
described above, to determine esophageal placement in 95 percent of cases (95% CI 88-98)
and tracheal placement in 93 percent (95% CI 86-97) [3]. (See 'Technique' above.)

● Adjunct for cricothyrotomy. There is an increasing body of evidence that ETI-aided

cricothyrotomy may be a sound alternative procedure to the standard surgical techniques.
(See "Emergency cricothyrotomy (cricothyroidotomy)", section on 'Rapid four step technique'.)

● Endotracheal tube exchanger. If an intubated patient has a malfunctioning ETT (eg, cuff
leak), an ETI can be advanced through the ETT to maintain a track into the trachea, over
which the malfunctioning ETT can be removed and a new ETT placed.

● Adjunct for video laryngoscopes. Some manufacturers (King Vision, Pentax AWS)
advocate use of an ETI to assist with difficult intubations [14,15]. In some video laryngoscopes
(Copilot VL), a specific channel for ETIs has been created to assist with routine intubations.
(See "Devices for difficult emergency airway management in adults outside the operating
room", section on 'Video laryngoscopes'.)

● Adjunct with blind digital intubation. Some practitioners prefer to use an ETI, rather than
an ETT, when performing digital intubations since the smaller diameter and malleability allow
for easier manipulation within the oropharynx when directing the tip towards the glottic
opening [16]. In addition, when the ETI enters the trachea, palpable clicks and a positive "stop

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sign" help to confirm proper placement, as opposed to digital intubations without an ETI in
which tactile confirmation of tracheal placement may not be possible. (See 'Technique' above.)

SUMMARY AND RECOMMENDATIONS

● The endotracheal tube introducer (ETI) is an effective and inexpensive adjunct to difficult
airway management that is easy to use. We recommend that an ETI be readily available in
every emergency department. The ETI consists of a 60 cm stylet with the distal tip bent at a
30 degree angle. The bend allows the intubator to direct the tip anteriorly under the epiglottis
and through the vocal cords. This orientation is required for the tip to encounter the anteriorly
located tracheal rings and produce palpable "clicks" when advancing into the trachea.

● The ETI is a useful tool for intubation when the epiglottis is visible but the vocal cords cannot
be seen (Grade III Cormack-Lehane view). The ETI can be used in conjunction with standard
laryngoscopes, video laryngoscopes, and fiberoptic intubation devices.

● An ETI should be used with caution if at all when there is possible laryngeal or tracheal injury.
In such cases the ETI may exacerbate the injury or be advanced outside the airway into
adjacent structures. An ETI is unlikely to be beneficial when no part of the airway can be seen
(Grade IV Cormack-Lehane view).

● The standard technique for inserting the ETI and using it for placement of an endotracheal
tube is described in the text, as are other potential uses for the device. Two tactile sensations
confirm correct placement in the trachea. One is the feeling of vibrations or "clicks" as the tip
of the ETI is advanced over the tracheal rings. Another is resistance to further insertion. (See
'Technique' above and 'Other uses' above.)

ACKNOWLEDGMENT

We are saddened by the death of Aaron E Bair, MD, MSc, FAAEM, FACEP, who passed away in
November 2018. UpToDate wishes to acknowledge Dr. Bair's past work as an author for this topic.

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