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The Bougie and Airway Management

Revisiting an Old Friend
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THOMAS C. MORT, MD
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Senior Anesthesiologist
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Hartford Hospital
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Clinical Professor of Anesthesiology and Surgery

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Department of Anesthesiology and Critical Care Medicine

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University of Connecticut School of Medicine

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Farmington, Conn.
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Dr. Mort reported no relevant financial disclosures.

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T
he role of the endotracheal
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tube introducer has been

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revered for five decades and

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is recognized as a valuable
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intubation adjunct.
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Introduction
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The endotracheal tube introducer (ETI), commonly Not Really a ‘Gum-Elastic Bougie’
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Your correspondent (Toyoyama et al. Anaesthesia

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referred to as a “bougie” or “gum elastic bougie,” is

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2002;57:932) seeks information about the

a useful intubation adjunct. It has been described as
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development of the ‘gum-elastic bougie’. I have

not made of gum, not elastic and not really a bougie
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researched this subject for a chapter ‘Intubation

(see callout).1-4
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techniques for unanticipated difficult direct

Perhaps our urological colleagues would argue that laryngoscopy: Stylets and introducers’ in a forthcoming
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the bougie, useful for urethral dilatation purposes, book ‘Derschwierige Atemweg, ed. Paschen and
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rose to prominence within their specialty. Sir Robert Dörges’, to be published by Springer. There is a
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R. Macintosh described the use of this catheter as an
introducing adjunct for difficult intubations in 1949.2
Many years passed until Venn designed the currently
used Eschmann introducer in the early 1970s, with
alterations in its construction material to provide more
stiffness while maintaining flexibility, lengthening it to
60 cm and adding the curved tip (35-degree coudé
tip) to improve maneuverability.3 These changes con-
tributed to the success of the ETI as an airway adjunct.
historical explanation for the inaccurate and confusing
terminology relating to the ‘bougie’. The ‘gum-elastic
bougie’ used so widely in the UK is not made of gum-
elastic, and is not used by anaesthetists as a bougie (a
device for serial dilation of strictures). The so-called
‘bougie’ is an introducer and the product used in the
UK is described by the manufacturers as an introducer.
J. J. Henderson. Excerpt from reference 4.

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 67
 Adopting the Seldinger-based placement of an intro-
ducer into the trachea to facilitate tracheal intubation
is widespread and is a mainstay in all the major airway
management guidelines.4-11 The development of the
gum elastic bougie was reviewed historically by Hen-
derson in a piece written in 2003, a portion of which is
quoted in the callout (page 67).4
The role of the ETI has been revered for five decades
and is recognized as a valuable intubation adjunct. Its
simple design, lack of moving parts, easy transport-
ability, absence of batteries to fail, quick learning curve,
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personnel, such as first responders.16,17,22,23 Its routine
elective use to assist with DL or VAL (with a non-hyper-
angulated blade) has shown promise by improving first-
pass success in the emergency department.21,25
There are a variety of ETI designs available to the
airway manager. The reusable Eschmann tracheal tube
introducer is considered the original and the gold stan-
dard. Multiple other manufacturers offer polyvinyl chlo-
ride/plastic designs, most with similar characteristics,
feel and length (50-70 cm) and a 14 Fr to 15 Fr diame-
ter that affords use with a variety of endotracheal tube

and adaptability to assist with other airway-related (ETT) sizes (5.5-9.0 mm).
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tasks favor its continued presence in any airway man- Each model has its own variable intrinsic bending or
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ager’s arsenal. shaping memory. This is important to appreciate since it

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Depending on the grade of the laryngeal view, the ETI may affect how one stores, cares for and transports the
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has accumulated an excellent success rate, in the range catheter (in the emergency airway bag) as well as its
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of 80% to 90% for the first attempt and rising to 94% to adaptability for use with DL and VAL devices (Figure 1).
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100% by the second attempt in a difficult airway situa- Most are single use and disposable to hasten cleanup
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tion.12-20 The success rate for the most restricted laryn- and reduce the potential for cross-contamination. How-
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geal views (IIIa, IIIb) is lower due to greater difficulty ever, the less expensive, disposable ETI seem to per-
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maneuvering the ETI tip underneath or around the epi- form less impressively in comparison to the Eschmann
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glottis. Its pairing with conventional direct laryngoscopy design (author’s view), and this is not an isolated opin-
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(DL) and video-assisted laryngoscopy (VAL, with con- ion.26-28 The Frova introducer (Cook Medical), which is
ventional blade design) provides support for its worthi- an alternative available in two sizes (8 Fr and 35-cm
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ness for inclusion in the difficult airway cart (DAC) or length or 14 Fr and 70-cm length), has a hollow design
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portable airway bag/suitcase, as well as in the OR, emer- with an optional metal stiffening cannula (rod) for the
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gency department and ICU (including non-OR anesthe- proximal two-thirds of the catheter. Moreover, a 15-mm
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sia [NORA] settings).12-22 Relatively high success rates adapter or luer lock connector is offered for optional
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have been duplicated by the novice and non-anesthesia oxygen delivery via the catheter. Whether to deploy
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reusable equipment (e.g., Eschmann) or disposable, sin-

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gle-use adjuncts is a question best handled at the local

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and institutional level based on economic factors and

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infection concerns.
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If reusable ETI equipment is provided, strict enforce-

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ment of its care and maintenance are important. An

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ineffective quality control program could allow repro-

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cessing and redistribution of damaged or misshaped

ETIs, or lack of disposal if they are past the recom-
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mended life span. There is further concern that the

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disposable models are stiffer and may have increased

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propensity for tracheal or bronchial injury, mucosal or

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otherwise.29-34 Injury may occur with an uneventful ETI

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insertion, eliciting a “click” or “hang up,” or while rail-

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roading the ETT over the ETI.

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Recently, a steerable ETI (with a directional tip) has

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been introduced (Flexible Tip Bougie, Sharn Anes-

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thesia), which affords improved maneuverability by

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offering anterior flexion of the ETI tip that may be par-

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ticularly helpful in navigating the restricted or difficult

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airway (i.e., grades IIIa, IIIb), especially when utiliz-

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Figure 1. ing a hyperangled VAL blade.35 Some clinicians have

Single-use disposable ETIs stored in a STAT airway
bag for NORA encounters (left) displaying a variety of
unintended curves due to storage conditions versus the
same ETIs and the Cook model Frova ETI (right) stored
in the anesthesia supply room.
ETI, endotracheal tube introducer; NORA, non–OR anesthesia
All photos courtesy of the author.
adapted an alternative to assist ETT maneuvering with
the hyperangled VAL, given the relative lack of a good
bougie alternative—that is, combining the VAL with
flexible fiber-optic bronchoscopy (FOB). The broncho-
scope becomes a maneuverable bougie with the added
advantage of FOB visualization combined with VAL-
assisted visualization. This technique does require at
least two experienced airway managers for best results.

68 A N E ST H E S I O LO GY N E WS .CO M
Indications
Classically, the ETI has been considered a valuable
adjunct for intubation when the epiglottic edge is vis-
ible along with a glimpse of the arytenoid/corniculate
complex (grade IIb) or when the glottic opening cannot
be viewed (modified Cormack-Lehane and Cook Lentis
grades IIIa or IIIb, Figure 2). The coudé tipped catheter
can be advanced across the underside of the epiglot-
tis in a grade IIb view with a high certainty of success,
and in many cases visualization with conventional DL or
VAL assistance allows the operator to confirm the ETI is
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placed within the glottis. Conversely, when the glottis
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is completely hidden (either grade IIIa, Cook “restricted”
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or grade IIIb, Cook “difficult”), manipulation of the ETI
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is more challenging.36 Grade IIIa is typically handled
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reasonably well with either a styleted ETT with the
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appropriate angle or, better yet, the ETI which affords
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navigation under or around the epiglottis. Managing the
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grade IIIb (Cook “difficult”, Figure 2) is certainly more
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challenging and has a higher rate of failure and mis-
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taken esophageal placement of the ETI, ETT or both.36
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Maintaining the angled tip anteriorly is best to assist
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with the ETI’s blind advancement and maneuvering. ETI
manipulation (gentle turning, twisting) may provide
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tactile feedback, especially to the experienced ETI user,
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of the coudé tip’s location with regard to the glottic
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opening. The ETI can be combined with DL, VAL (con-
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ventional blade angle) or FOB. Conversely, incorporat-
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ing the ETI is valuable when the operator achieves a
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complete view of the laryngeal inlet (grades I and IIa,
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or Cook “easy”) or a partial view of the glottis but cer-
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tainly as restricted as a grade IIIa (or grade IIb, Cook
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“restricted” view). Passage of the ETI should be fairly
easy and be accomplished with high accuracy. This
describes the theory of Driver et al who proposed elec-
tive ETI use for every intubation to improve first-pass
success.25
Despite achieving a good to excellent view of the
glottic inlet, accurate and timely ETT advancement into
the trachea still may be difficult. For example, in the
obese patient with excessive, redundant pharyngeal
tissue and a crowded hypopharynx, one may obtain a
full or partial view of the glottis, yet the pathway to
the glottis may be narrow or confined. Advancement of
the ETT essentially blocks the line of sight, leading to a
GRADE I GRADE IIA GRADE IIB
EASY RESTRICTED
Figure 2.
Modified Lehane-Cormack Lentis Cook Laryngeal Grading System.36
Drawing courtesy of A. Mort and M.E. Mort.
difficult intubation. Blocking the operator’s line of sight
may occur in an otherwise straightforward airway. The
blocked line of sight may lead to ETT tip deflection lat-
erally or posteriorly, leading to failure, or the ETT may
be placed into the esophagus. The slender contour of
the ETI may be more easily maneuvered into the tra-
chea in these situations.
The Hames group studied the success rates for tra-
cheal intubation of 64 healthy patients during simu-
lated grade III laryngoscopy after induction of general
anesthesia.28 They compared the single-use ETI and
FOB, both in conjunction with conventional Macintosh
DL. Patients underwent simulated grade IIIa or grade
IIIb laryngoscopy randomly and were intubated using
one of the two devices. Success rates for FOB-based
intubation were 16 of 16 grade IIIa and eight of 16 grade
IIIB views compared with ETI results of eight of 16 grade
IIIa and one of 16 grade IIIb views. These findings rein-
force Cook’s designations of “restricted” and “difficult”
views (i.e., grades IIIa and IIIb).36
Practitioners often reserve the ETI as a rescue
device after failed intubation or when confronted by a
“restricted” or “difficult” laryngeal view. The elective role
of the ETI was recently investigated. Reports suggested
that elective, routine use of an ETI increases first-pass
success rates for both DL and VAL (Karl Storz C-Mac
blade or GlideScope [Verathon] titanium MAC blade,
excluding the hyperangled model VAL blade). The
investigating group used the SunMed ETI (15 Fr, 70-cm
length, single use). Driver et al reported that first-pass
intubation success was higher in the elective ETI use
group, at 98% versus 87%. In specific airway circum-
stances, such as in the obese patient, the presence of
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a hard cervical collar, a restricted laryngeal view with
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laryngoscopy or patients with a predicted difficult air-
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way, the differences were more profound, suggesting
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elective ETI may improve patient safety by increasing
the efficiency for first-pass success.25
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In either laryngoscopic choice (DL or VAL), the oper-
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ator’s temporary loss of laryngeal viewing (line of sight)
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from the advancing ETT may reduce accurate and timely
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ETT advancement into the trachea. Routine ETI place-
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ment typically does not interfere with the operator’s
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line of sight due to the ETI’s slender design, cuff-free
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contour and color vibrancy (blue or yellowish-orange vs.
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GRADE IIIA GRADE IIIB GRADE IV
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DIFFICULT
A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 69
clear, compared with a conventional ETT), thus improv-
ing the accuracy of ETT advancement (i.e., first-pass
success).
Combining the ETI with VAL will vary by the type
of VAL device: Factors include channeled or nonchan-
neled, and blade angulation (more conventional angle:
25 to 35 degrees vs. hyperangulated: 65 to 70 degrees).
A channeled VAL allows the ETI to be placed within
the ETT to assist with tracheal intubation. Models such
as the Airtraq (Prodol Meditec; Figure 3), King Vision
(Ambu), Pentax AWS, and CoPilot VL+ (Dilon Technolo-
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a shape and be rendered useless to the airway team at
the time it is deployed.
It was once unofficially recommended to me by a col-
league that to ensure a proper bougie curve, one could
pass and carry the ETI within the drawstring waist com-
partment of one’s scrubs. Other ETI models do perform
better regarding intrinsic shape memory. It is best to
review several ETI models before committing to a brand
that does not meet your needs, particularly if you plan
to use it with both DL and hyperangulated VAL devices.
Alternatively, using a steerable ETI may assist

gies) work well when combined with the ETI. Freehand advancement not only with conventional angle blades
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advancement of the ETI with conventionally angled VAL but also when combined with the hyperangulated VAL
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models can be utilized with or without video-assisted blades.35 One model, the Flexible Tip Bougie is adapt-
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viewing. Use of the ETI with a hyperangled VAL model, able to both DL and VAL. The ETI has a slider on the
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such as the GlideScope (Verathon) or D-Blade (Karl proximal end of the device that allows manipulation by
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Storz), may be more challenging due to the 65- to the operator’s thumb and forefinger to adjust the ante-
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70-degree angle that the ETI needs to navigate. rior or posterior tip angle. This innovative design does
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The Hartford Hospital NORA management database require some practice to master so that the operator
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had 12 encounters on record that combined a single-use, may easily flex, straighten or retroflex the tip to assist
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disposable ETI with the hyperangled GlideScope VAL. with transglottic placement.
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Each ETI attempt failed due to the inability to maintain

ETI Advancement
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a consistent angulation to allow accurate and timely

Use of the ETI should best be performed as a two-
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maneuvering around the 65-degree VAL blade. Some

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ETI models, depending on the introducer’s composite person procedure, at minimum. Typically, the ETI
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materials, may allow the operator to bend or angle the is being used as a rescue adjunct with DL due to a
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ETI to provide the proper curvature to ease advance- restricted laryngeal view. The operator will pass the
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ment and maneuverability around the VAL blade. ETI into the trachea, followed by passage or railroad-
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Other models have little or no intrinsic shape mem- ing of the ETT over the ETI. It is imperative to maintain
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ory when angled/shaped as they return to their native the laryngoscope in place to keep the pathway open to
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stored shape. For example, in the author’s hands, uti- ease ETT advancement and allow the bougie to retain a
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lizing a single-use ETI that has been stored to maintain straighter line and thus facilitate intubation.37
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its factory-provided straight shape, then attempting to Secondly, it is equally important that the assistant
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induce an appropriate curve for use with the GlideS- firmly holds the proximal end of the ETI in position
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cope, is rarely successful (Figure 1). The ETI only retains while the ETT is advanced/railroaded into the airway.
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a curve momentarily. However, if the ETI is carried in an The vector of force of ETT advancement will very likely
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airway travel bag and placed around the periphery of advance an unheld ETI distally, and this could injure
the travel bag, maintaining it in a semicircular fashion, the tracheobronchial tree. It is a reasonable expecta-
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when removed for use the curve will likely remain intact, tion that the team members openly communicate with
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even despite efforts to straighten it. Conversely, if the each other to assign their roles in the airway manage-
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ETI is stored folded over or angled, it may retain such ment schema. Commonly, the operator who places the
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Figure 3.
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A loaded disposable Airtraq with

ETT and ETI in its channeled
blade delivery system.
Figure 4.
The ETI may assist the operator
in gaining access to the laryngeal ETI resting on the
inlet to allow more accurate ETT posterior chink of
placement. the glottic opening.
ETI, endotracheal tube introducer; ETI, endotracheal tube
ETT, endotracheal tube introducer

70 A N E ST H E S I O LO GY N E WS .CO M
ETI would maintain the laryngoscope with their left
hand. While maintaining the ETI at the decided depth,
the assistant places a lubricated ETT on the ETI and
advances it while they or a second assistant secures
the ETI in position. Then, while maintaining the ETI at
its prescribed depth, the operator advances the ETT.
While advancing the ETT, one has two choices of
how to proceed:
• Simply advance the ETT forward down the ETI.
If resistance is encountered, stop ETT advance-
ment, withdrawal the ETT 1-2 cm, turn the ETT
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Tip impingement is common due to the right-side
location of the bevel on the standard ETT. The typical
position of the ETI is the “posterior chink,” as presented
in Figure 4. It will be held up by the glottic chink, the
arytenoid/corniculate cartilage or the vocal cord, typi-
cally on the right (Figures 5 and 6). Other factors that
influence the ease of ETT advancement are maintaining
the presence of the laryngoscope to allow the pathway
to remain open, minimizing the gap between the ETI
and the ETT and lubrication.
Alternatively, one may pre-insert the ETI within the

90 degrees counterclockwise and then re- tracheal tube so the distal ETI tip is protruding (5-8 cm)
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advance the ETT, or from the ETT tip. The ETI–ETT unit is then used together
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• The operator could pre-emptively twist/turn the for tracheal intubation. The preformed curve of the
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ETT 90 degrees counterclockwise as the ETT is new ETT may add the needed curvature to the ETI to
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advanced.38 improve its navigation into the glottic opening.

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Figure 5.
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Depiction of ETT encountering tip/bevel impingement on the right lower posterior portion of the glottis during its
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advancement over the ETI (left image).

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Corrective action is to halt advancement and retract the ETT 1-2 cm to allow the tip to clear the glottic tissue then turn the
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ETT 90 degrees counterclockwise (middle image).

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Note that following the 90-degree counterclockwise rotation, the bevel is anterior. The ETT can then be re-advanced and
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likely will pass freely into the trachea (right image).

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ETI, endotracheal tube introducer; ETT, endotracheal tube

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Drawing courtesy of M.E. Mort.

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Figure 6.
Posterior glottic structures: Nearly 97% of observed AEC plus ETI lie against the posterior hypopharyngeal wall buried
in the mucosa. The anterior angle taken by the AEC/ETI to traverse the glottis explains why 95% of AEC/ETI lie in the
posterior glottic chink. Mannequin (left) and human (right).
AEC, airway exchange catheter; ETI, endotracheal tube introducer

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 71
Tactile Feedback
Many advocate the importance of the tactile feed-
back to the operator’s fingers when using the ETI. The
first feedback, via the tracheal clicks, may provide a
reassuring sign of tracheal placement. The tactile feed-
back will be appreciated by both the operator han-
dling the ETI and the assistant providing the so-called
BURP (backward, upward, rightward pressure) maneu-
ver, or cricoid pressure, or optimal external laryngeal
manipulation.
The angled coudé tip should be maintained in an
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The second tactile sign that may suggest correct tra-
cheal placement is encountering insertion resistance
from the carina and distal bronchopulmonary anatomy.
Depending on the adult patient’s height and tracheo-
bronchial tree dimensions, gentle ETI advancement
to between 22 and 40 cm from the gum–dentition
line may meet resistance by the distal ETI tip getting
hung up on the carina or the secondary bronchi. This
should distinguish itself from smooth unobstructed ETI
advancement within the esophagus, barring any esoph-
ageal pathology or anatomic alterations. This is referred

anterior direction to improve the chance of encoun- to as the “hang-up,” “stop sign,” “hard stop,” or a posi-
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tering the tracheal rings (Figure 7). Depending on the tive Cheney sign.
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angle of advancement, the straight or curved shape of Conversely, if the ETI is placed within the esopha-
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the ETI and the coudé tip direction, tracheal clicks may gus, the clicks should not be appreciated, and the ETI
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or may not be appreciated. Too much dependence on should advance unopposed through the esophagus
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the presence or absence of tracheal clicks should be and into the stomach (depth >35-45 cm). It is imper-
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discouraged. It should be taught to the novice operator ative to gently advance the ETI in search of the hang-
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as an interesting and potentially helpful clinical obser- up sign to reduce the potential for injury.39 Following
20

vation, rather than as an all-or-none test. its detection, the depth of the ETI should be noted and
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I have observed, on numerous occasions, a lack of the ETI should be retracted by 3 to 6 cm, depending
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clicks followed by the more reliable distal tip carinal/ on its depth and the patient’s height. The proximal end
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bronchial hang up or “stop sign,” confirming correct ETI of the ETI must be secured and held in position by an
placement in the trachea, particularly in the emergency assistant during ETT advancement (railroading). This is
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setting. The elective use of the ETI in the OR with a pre- important to perform to reduce tip-induced damage to
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viously unintubated “virgin trachea” seems more likely the tracheobronchial tree. The vector of force of the
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to produce the clicks compared with an emergency advancing ETT may push the unsecured ETI more dis-
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NORA patient. I have less commonly appreciated the tally, leading to tip impingement and possible mucosal
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clicks under emergency circumstances, particularly in or cartilaginous injury.39

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the patient who has recently undergone airway manip- It is well known that airway trauma may occur with
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ulation (previous intubation, self-extubation, volume laryngoscopy and placement of the ETT. Various fac-
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resuscitation, tracheobronchitis, pneumonia, etc.). tors influence its occurrence and degree of injury:
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• the patient’s head/neck anatomy,

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• ETT size and construction characteristics,

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• force vectors applied,

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• operator (in)experience,
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• stylet used, and

• ease or difficulties encountered, and coagulation
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status, among other factors.

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Serious intubation injury is uncommon but real. Now,

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the addition of the use of an ETI on top of all this is

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another source of potential injury.

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Proceed Gently
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While there are numerous case reports of ETI-

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related injuries, some quite serious and life-threaten-

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ing, the exact numerator and denominator to determine

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the true incidence are not known. If the ETI is utilized

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properly and gently, injury should be rare, but it has

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had some devastating consequences.29-34,39 Reports of

d.

injury were nearly nonexistent prior to the marketing of

Figure 7.
Tracheal clicks. With the ETI’s coudé tip angled
anteriorly, ETI advancement may offer tactile feedback
to the intubator and the assistant who is applying neck
manipulation.
ETI, endotracheal tube introducer
the disposable ETI models. Does this mean the reusable
Eschmann is kinder and gentler (than the disposables)
or is it the operator holding it? Has the relatively unreg-
ulated market of disposables ushered in a new wave of
introducer-related injuries?
There appears to be distinguishing differences among
ETI tip and shaft stiffness of the various models avail-
able.40,41 Excessive force applied to any instrument is

72 A N E ST H E S I O LO GY N E WS .CO M
 typically frowned upon, especially in the airway. The ETI
in general should not be forced or advanced excessively.
However, we need to separate ETI placement alone ver-
sus performing confirmatory tests to assist the airway
team in determining its location (trachea vs. esophagus)
prior to ETT advancement. The forces generated during
attempts to prompt the hang-up sign and those needed
to cause perforation are likely very different.
This is the reason gentle advancement permeates
this writing. The disposable models appear to be more
likely to injure or perforate than the Eschmann intro-
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ducer, based on tip design and stiffness. So it falls back
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on the operator and their willingness and ability to
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either avoid the hang-up sign altogether or apply it with
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the utmost gentleness.
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As a potential compromise, the ETI may be accom-
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panied by a laryngeal view that affords visualization of
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its position within the trachea (grades I, IIa and IIb). So,
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is there a need to perform the hang-up test in these
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clinical situations? It is most applicable when the ETI
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is passed blindly into the trachea (grades IIIa and IIIb).
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The hang-up sign has a reported nearly universal suc-
cM
od
cess in differentiating the trachea from the esopha-
uc
gus. It is absolutely fair and reasonable to always apply
ah in w
gentleness to the airway. If you have to apply exces-
tio
on
sive force during intubation, something is likely wrong.
n
Pu
Trying harder could increase the potential for injury. It
bl
would be best to change your approach or technique.
is
Should we abandon the hang-up sign due to the
ho
hi
small but real chance of injury? We do not know the
ng
le
true incidence of injury related to ETI use. Should the
or
hang-up test be reserved for only grade IIb and IIIa
ro
in
views? Since the rate of failed intubation with the Cook
up
“difficult” grade IIIb is significant, even with using the
ETI as an adjunct, should the ETI not even be utilized
in grade IIIb?
When one deals with a grade IIIa or, more specif-
ically, a grade IIIb laryngeal view, there is significant
risk for blindly advancing the ETI into the esophagus.
If this occurs in the elective surgical procedure in an
NPO patient without aspiration risk, accidental esopha-
geal intubation has a low risk for life-threatening conse-
quences. However, the emergency NORA intubation in
the ICU, emergency department, radiology or the ward
is a much higher risk environment.
If we continue to deploy the ETI but abandon the con-
firmatory testing due to fear of an uncommon though
possible consequence, patient injury from airway and
hemodynamic complications related to ETI misplace-
ment followed by esophageal intubation will likely arise.
Reviewing the Hartford Hospital NORA management
database, ETI-assisted intubation in grades IIIa and IIIb
cases are the most likely to cause patient harm due to a
misguided ETI with subsequent esophageal intubation.
Despite timely recognition of ETT misplacement with
end-tidal carbon dioxide (EtCO2) monitoring and other
tests, esophageal intubation has an increased risk for
life-threatening hypoxemia, bradycardia, regurgitation,
aspiration, multiple intubation attempts and cardiac
arrest. Should we advocate that a gentle hang-up test
be pursued, at least in patients with grades IIIa and IIIb
laryngeal views, particularly in the emergency or criti-
cal care setting?
Tips and Caveats
Any NORA management procedure is best handled
by the team approach with at least one knowledge-
able or teachable assistant at the bedside. If you must
deliver care as the sole practitioner, it will be best to
recruit help at the bedside and provide point-of-care
teaching and instructions to optimize patient care. In
either case, announcing the role of each team member
is key to minimize duplication of steps/actions by dif-
ferent team members who then may neglect another
important step.
There are several jobs: the “scoper,” the loader, the
holder and the passer. Some team members may per-
form more than one task, but clear communication
announcing each assigned role should reduce confu-
sion. The jobs include the need to maintain the laryn-
goscope in position (the scoper); placement of the ETT
on the ETI (the loader); maintaining control of the prox-
imal ETI so it remains at the same depth during ETT
advancement (the holder); and advancement of the
ETT (the passer).
Easing ETT advancement over any conduit by apply-
ing lubricant on the ETI and the inner and outer edges
of the ETT tip is highly recommended. In the rush to
secure the airway, particularly if the ETI is utilized as
a rescue measure, lubricant may be forgotten. This is
particularly important in the patient with dry mucosal
membranes. Pushing an unlubricated ETT over a dry
pa
ETI that is advancing past dry mucosal structures may
un ou
be difficult or impossible, and securing the airway will
rt
thus be delayed. Moreover, advancing a dry or inade-
w
le
ith
ss
quately lubricated ETT over the ETI will increase the
vector force applied to the ETI and potentially advance
ot
it more distally, even if held securely by the “holder.”
he
tp
Maintaining ETI position by an assistant (the holder)
rw
er
is imperative to avoid proximal ETI retraction or more
is
m
distal ETI advancement. Furthermore, maintaining the
e
is
presence of the laryngoscope blade in the oro-hypo-
no
si
on
pharynx is quite helpful for assisting with ETT advance-
te
ment as it keeps the pathway open. ETT advancement
d.
is
may be met with resistance along the length of the
pr
ETI. Many ETI models offer depth markings to assist
oh
the intubator in estimating the ETI’s position. Like-
ib
wise, appreciation of the ETT depth markings may pro-
ite
vide valuable feedback to the cause of resistance or
d.
advancement failure.
Resistance at a shallow depth of 10 to 13 cm may
likely be redundant tissue or the epiglottis. Resistance
felt at 16 to 17 cm (in a patient of average height) likely
is the arytenoid/corniculate cartilage, posterior glottic
chink or the vocal cord, typically on the right side. The
standard ETT tip bevel is protruding on the right side
of the ETI and tends to catch or lodge on the right side
of the glottis.42-45
A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 73
 Once resistance is encountered, it is best to halt ETT
advancement rather than to apply further force. Then
withdraw the ETT 1 to 2 cm, turn the ETT 90 degrees
counterclockwise, then re-advance the ETT. Cossham
described this issue38 and proposed its solution in 1985,
by commenting that when:
“encountering resistance, one automatically
tends to rotate it clockwise, as if inserting a
bolt or screw, thus causing the tip of the tube
to lie posterior to the bougie, protruding
A
ETT exchange over an airway exchange catheter (AEC).
The 90-degree counterclockwise turn is applicable also
to nasal intubation, whether intubation is freehand or
over a conduit. Applied cricoid pressure may increase
impingement of the ETT tip on the glottic structures.
Despite incorporating the 90-degree counterclockwise
twist, release of cricoid pressure may allow successful
passage of the ETT.47
Minimizing the Gap: Another factor that has a signif-
icant impact on ETT passage is the principle of “min-
imizing the gap” as it applies to any Seldinger-based

like a ploughshare lodging firmly behind procedure. Placing a large-bore central venous line
ll

the arytenoids. I suggest that, before the starts with attaining venous access via a small catheter/
rig

Co

tube nears the larynx, it should be rotated a needle, passing a wire into the vein, “enlarging” the wire
ht

py

quarter-turn anti-clockwise. This manoeuvre by passing an obturator sleeve over the wire, and then
s

rig ed.

will cause the tip of the tube to lie anterior advancing the large-bore venous catheter. This prin-
re

to the bougie, and to be in close contact ciple also applies to passage of an ETT over an AEC,
ht
se

with the bougie, so that it does not catch bronchoscope or ETI. Proper pairing of the two devices
rv

on anything. The tube must previously have may reduce intubation attempts, decrease intubation
20

been lubricated inside and outside.” failure and frustration, and improve the patient’s safety.
20
Re

Minimizing the gap allows the ETT to pass with a

M
pr

His clever observation is applicable to a number firm trajectory, snugly over a well-matched conduit, and
cM
od

of situations of Seldinger-based ETT advancement; there will be fewer encounters of tip/bevel impinge-
namely, the ETI, bronchoscopic-assisted intubation and
uc

ment on airway tissues, the vocal cord, arytenoid and

ah in w

corniculate cartilages, or the posterior ”chink,” par-

tio

on

ticular toward the right. Table 1 displays the external

n

Pu

or outer diameter of the common ETI and AEC mod-

Table 1. Mind the Gap:
bl

els as well as the cross-sectional area. Passing the

Comparison of Outer Diameter and
is

larger 9.0 ETT over a 14-Fr ETI would allow excessive

ho

hi

Cross-Sectional Area ETT wobble and increase its tip impingement as it tra-
ng
le

versed the airway. Pairing them to minimize the gap will

or

Device: Outer Diameter Cross-Sectional afford smooth and timely advancement and reduce the
ro
in

(description) Area (~mm2 ) chance of bevel/tip injury from engaging the posterior
up
pa

11 Fr: 3.7 mm (small Cook AEC) 11 chink and the arytenoid–corniculate complex, particu-
larly on the right portion of the glottis (Figures 4-6).42-45
un ou
rt

14 Fr: 4.7 mm 17 An alternative ETT choice is the Parker Flex-Tip

w

le

(medium Cook AEC, bougie)

ith

ss

(Parker Medical), which is equipped with an anteri-

orly directed bevel combined with a flexible, tapered
ot

15 Fr: 5.0 mm (bougie) 19.6

tip to reduce hang up (Figure 8). Its design reduces
he
tp

19 Fr: 6.3 mm (large Cook AEC) 31

rw
er

ETTa
is
m

e
is

6.0 mm OD 28
no
si
on

te

6.5 mm OD 33
d.
is

7.0 mm ID, 9.5 mm OD, 38

pr

Evac: 10.4 mm OD
oh

8.0 mm ID, 10.8 mm OD, 50

ib

Evac: 11.8 mm OD
ite

Figure 8.
d.

9.0 mm ID, 11.9 mm OD, 64

Evac: 13.1 mm OD
a
Commonly used ETTs in a NORA management situation
are equipped with subglottic suction capabilities (Evac),
which increases the outer diameter by approximately 0.9 to
1.0 cm: for example, standard 7.0 mm I.D., 9.5 mm OD versus
subglottic Evac model, 10.4 mm OD.
AEC, airway exchange catheter; ETT, endotracheal tube;
ID, inner diameter; OD, outer diameter
Minimizing the ETI–ETT gap is important to ease
advancement through the glottic opening. The Parker
Flex-Tip ETT (left), with its distinctive “bird beak” tip,
provides the Cossham twist with a centered bevel
positioned anteriorly combined with a flexible, tapered
tip to reduce hang up. Note the tip hugging the ETI to
assist with minimizing the gap (right).
ETI, endotracheal tube introducer; ETT, endotracheal tube

74 A N E ST H E S I O LO GY N E WS .CO M
tip impingement without having to employ the coun-
terclockwise (“Cossham”) twist, though twisting may
assist with advancement.38 Use of this ETT model is
fine for the OR and short-term use, but it has been
poorly accepted as a longer term (>24 hours) ETT
in an ICU setting due to it potential for leaking, high
cuff pressures and lack of the subglottic suction role
(author’s opinion). Once placed in the NORA patient
who requires extended mechanical ventilation, the
ETT’s limitations, as noted above, most often require
the patient to undergo a high-risk ETT exchange after
A
ETT. This upsizing may impact ETT advancement
despite one’s efforts to “minimize the gap.” The “min-
imizing the gap” principle is supported by data from
Hartford Hospital’s NORA management database on
AEC-assisted ETT exchange, which clearly demon-
strates the influence of minimizing the gap on first-
pass success. For example, in over 800 AEC-assisted
ETT exchanges involving passing a new 8.0 ETT over
an AEC, the first-pass success rate varied widely: 11 Fr,
43%; 14 Fr, 79%; and 19 Fr, 91%. There is a strong rela-
tionship between minimizing the gap and improved

24 to 48 hours in the ICU. patient safety (increased first-pass success, decreased

ll

Another factor to consider is the bevel/tip burden- hypoxemia of any level, decreased severe hypox-
rig

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that is upsized by using the specialty ETT with sub- emia [saturation <80%] and decreased bradycardia,
ht

py

glottic suction capabilities (Evac, Shiley). The external by nearly 70% [comparing 11 Fr and 14 Fr and 19 Fr]).
s

rig ed.

diameter is approximately 1 cm larger than a standard See Figures 9-13.

re

ht
se
rv

©
20
20
Re

M
pr

cM
od
uc

ah in w
tio

on
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Pu
bl
is
ho

hi
ng
le
or

G
ro
in

up

Figure 9.
pa

un ou
rt

6.0 ETT over 15-Fr ETI. Left: The bevel toward the right displays minimal impingement on glottic structures due to the small
w

le

gap between the ETI and ETT. Right: The 90-degree Cossham twist turns the bevel upward (note the Murphy eye), allowing
ith

ss

smooth advancement.
ot
he
tp

rw
er

is
m

e
is

no
si
on

te
d.
is
pr
oh
ib
ite
d.

Figure 10.
7.0 ETT via ETI. Left: With the bevel toward the right, note the impingement of the ETT tip on the arytenoid and posterior
chink. Right: The 90-degree Cossham twist frees the bevel/tip to improve passage through the glottis.
ETI, endotracheal tube introducer; ETT, endotracheal tube

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 75
 A
ll

Figure 11.
rig

Co

8.0 ETT via 15-Fr ETI. Left: Note significant overlap of bevel/tip of ETT posteriorly due to widening gap between ETI and
ht

py

ETT. Right: The 90-degree Cossham twist (likely 120-degree turn) centers the ETT and reduces tip impingement.
s

rig ed.
re

ETI, endotracheal tube introducer; ETT, endotracheal tube

ht
se
rv

©
20
20
Re

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pr

cM
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uc

ah in w
tio

on
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bl
is
ho

hi
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Figure 12.
or

G
ro
in

9.0 ETT via 15-Fr ETI. Left: Note significant tip/bevel impingement in the posterior-rightward direction with the ETT load
up
pa

in the standard position on the ETI. Right: The 90-degree Cossham twist affords improved navigation through the glottis
despite the sizable gap between the ETI and ETT.
un ou
rt

ETI, endotracheal tube introducer; ETT, endotracheal tube

w

le
ith

ss
ot
he
tp

rw
er

is
m

e
is

no
si
on

te
d.
is
pr
oh
ib
ite
d.

Figure 13.
ETI passed into a plastic trachea model (not part of a mannequin head/neck). This allows a more direct approach for the
ETI to take without it bending around the mouth-oral cavity-oropharynx-hypopharynx passage, which leads to it arching
and being buried into the posterior pharyngeal wall. Its subsequent anterior vector to enter the glottic opening nearly
assures its position in close proximity to the posterior glottic structures, enhancing the chance for ETT tip impingement.
Conversely, when the ETI is not arched around the passage, it tends to lie in the middle of the glottic opening (left), thus
offering nearly unopposed ETT advancement (right), even with a larger caliber ETT.
ETI, endotracheal tube introducer; ETT, endotracheal tube

76 A N E ST H E S I O LO GY N E WS .CO M
 When traversing the curvature from the mouth open-
ing down to the glottic opening, the ETI, similar to the
FOB insertion cord or shaft of the AEC, has a tendency
to arch against the posterior portion of the oro-hypo-
pharynx. As the shaft angles slightly anterior to rise from
the posterior wall to enter the trachea, it comes to rest
in the most posterior portion of the glottic opening, sur-
rounded by the posterior portion of the vocal cords, the
arytenoid and corniculate cartilages, and the posterior
chink. The posterior position hampers ETT advancement
by promoting impingement, especially with a larger ETT
A
Additional Airway Tasks
Tracheostomy exchange/reintubation/recannulation:
In both the elective setting and urgent/emergent cir-
cumstances, the ETI is a valuable airway adjunct. Elective
upsizing/downsizing or changing the type or age (i.e.,
fresh or mature) of tracheostomy tube may be assisted
with adjunctive use of the ETI. During urgent/emergent
loss of the airway requiring either reinsertion of the tra-
cheostomy or temporizing with an ETT via the stoma,
due to accidental decannulation, emergency decannu-
lation for obstruction or displacement, or perhaps cuff

(8.0-9.0 mm) coupled with a smaller ETI. leak/rupture, the ETI may offer valuable assistance for
ll

This principle is influential in choosing the optimal reestablishing the airway. Gentle ETI advancement via
rig

Co

FOB, AEC or ETI to minimize the gap as it relates to the tracheostomy should be practiced. ETI advancement
ht

py

the desired ETT caliber. Patient safety is improved by into a false passage in the lateral tissues or pre-tracheal
s

rig ed.

minimizing the gap. This principle is influential in the space is not impossible. If resistance is encountered, FOB
re

marriage of the smaller caliber “anesthesia” FOB (typ- visualization of the airway is recommended.
ht
se

ically 3.5-4.2 mm in size) with the Aintree intubating Surgical airway access: There are several methods
rv

catheter (AIC). The highly touted “FOB plus AIC plus and techniques for securing an emergent surgical air-
20

SGA” (supraglottic airway) rescue combination allows way. Called variously a scalpel-bougie-cricothyrotomy,
20
Re

the delivery of a larger-bore ETT introducer through a scalpel-finger-bougie cricothyrotomy or a bougie-

M
pr

an SGA so the airway team may more accurately pass aided cricothyrotomy, the method is gaining traction
cM
od

a standard 7.0- to 9.0-mm ETT into the trachea via the as an accepted and preferred technique for provid-
AIC.47,48 Table 2 summarizes tips and caveats of note.
uc

ing emergency airway access. Following skin incision,

ah in w
tio

on
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Table 2. Tips and Caveats Worth Noting

bl
is
ho

ETI-assisted intubation is a two- or three-person procedure. Single practitioners should obtain help.
hi
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le

Lubrication is a basic requirement for Seldinger ETT advancement procedures.

or

G
ro

Understand the intrinsic “memory” of your ETI model and how it may affect DL/VAL success.
in

up
pa

Tracheal clicks are helpful but are neither mandatory nor confirmatory.
un ou
rt

Elective ETI may improve 1st-pass success and for at-risk patients (e.g., obese, C-spine, difficult airway traits).
w

le
ith

ss

Gentle ETI tip hang-up sign (Cheney’s sign) is valuable in distinguishing the trachea from the esophagus.
ot
he

Maintain laryngoscopy during ETT advancement (keep the pathway open).

tp

rw
er

Following hang up, withdraw ETI 3-5 cm, second person maintains ETI position, then advance ETT.
is
m

Gentle pursuit of hang-up sign is recommended for blind ETI insertion (grades IIIa, IIIb).
is

no
si
on

Mind the gap; larger ETT sizes (7.5-9.0 mm) increase the tip catching arytenoid/corniculate/vocal cord.
te
d.
is

Preemptive ETT twisting 90 degrees counterclockwise is helpful in reducing tip impingement on the glottic structures.
pr

Resistance to advancement at 16-18 cm depth typically means ETT is against the glottic structures.
oh
ib

If resistance is met with ETT advancement, stop, withdraw ETT 1-2 cm, turn counterclockwise 90 degrees,
ite

then advance again.

d.

Grade IIIb has a high failure rate, so prepare for likely ETI failure and think ahead/preplan for next adjunct.

Teach/practice ETI use in the mannequin and elective setting to share with the next generation.

Routine, elective ETI utilization improves 1st-pass success rate with DL and VAL (not hyperangulated blades).

Ensure ETI access in elective and emergency settings for its variable airway management roles.

ETI, endotracheal tube introducer; ETT, endotracheal tube

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 77
tissue spreading and incision of the cricothyroid mem-
brane or tracheal cartilage, bougie-assisted advance-
ment of a smaller caliber ETT (6.0 mm) via the stoma is
performed. Likewise, a smaller sized tracheostomy tube
may be advanced over the ETI. FOB visualization of the
airway is recommended after establishing surgical air-
way access in the NORA setting.
ETT exchange: An ETT exchange procedure is con-
sidered a high-risk procedure. If possible, maintaining
continuous access to the airway is best. Some advocate
the ETI as a useful method of maintaining continuous
A
airway access while exchanging an ETT. Although use-
ll
ful for this task, the ETI may not be the best alternative
rig
Co
due to its shorter length and smaller caliber (14-15 Fr)
ht
py
compared with use of a larger diameter and longer
s
rig ed.
catheter, such as a 19 Fr Cook Airway Exchange Cathe-
re
ter (CAEC). The longer length CAEC allows the team to
ht
se
maintain better proximal and distal control of the cath-
rv
eter during the removal of the preexisting ETT and the
20
passing of the new replacement ETT. If the ETI is passed
20
Re
either too deeply or too shallowly, exchange may be
M
pr
hampered. Moreover, the ETI is typically 14 to 15 Fr in
cM
od
caliber, similar to the medium CAEC. The Seldinger-
uc
based exchange is best served by minimizing the gap
ah in w
between the ETT and the catheter. Thus, upsizing to the
tio
on
large CAEC (19 Fr) for placing a 7.0- to 9.0-mm ETT in
n
Pu
adults is best with fewer attempts overall, a higher first-
bl
pass success rate and lower desaturation rates (due to
is
a more efficient exchange).
ho
hi
Some clinical situations do call for a 14-Fr CAEC
ng
le
(e.g., smaller caliber ETT, ETT damage, kinking, lumi-
or
nal narrowing), but the overall length of most ETI mod-
els remains a drawback for the exchange procedure.
The longer length version of the disposable ETI (70 vs.
50-60 cm) would be preferred if an ETI is used for ETT
exchange in the adult patient.
ETI-guided insertion of the ProSeal LMA: Some have
advocated placing a lubricated ETI in the gastric drain-
age portal of a second-generation SGA, such as the LMA
ProSeal or LMA Supreme (both by Teleflex) to assist
with placement of the SGA.49 In combination with DL to
assist placement, the ETI is passed into the esophagus
to allow delivery of the SGA to the level of the cricopha-
ryngeal opening. A principal cause of failed SGA place-
ment with standard digital insertion is cuff impaction
at the back of the mouth leading to failed passage into
the pharynx, folding over of the cuff, or the cuff being
directed into the glottic inlet instead of the hypophar-
ynx. Described as the gum elastic bougie–guided tech-
nique by Brimacombe, it reduces impaction at the back
of the mouth, prevents folding over of the distal cuff,
and guides the distal cuff directly into the hypopharynx.
Moreover, gastric tube insertion via the gastric portal
should have a high success rate because the drainage
tube and esophagus have improved alignment.49
ETT position confirmation: During cardiac arrest or
when EtCO2 monitoring is malfunctioning or unavail-
able, advancement of the ETI via the ETT may help ver-
ify ETT placement within the trachea. Passing an ETI
78 A N E ST H E S I O LO GY N E WS .CO M
provides feedback by the hang-up sign, the stop sign
or Cheney’s sign (ETI tip against the carina or second
bronchus at 27- to 37-cm depth in most patients (as
described above). Free, unopposed ETI advancement
to 40 cm and beyond would strongly suggest a pres-
ence within a patent esophagus, barring any stricture,
mass effect, pathology or significant hiatal hernia.
Extubation of the known/suspected difficult airway
patient: Maintaining continuous access to the airway
post-extubation by incorporating a conduit for reintu-
bation is an excellent schema in an attempt to maintain
a bridge to ease reintubation. The indwelling conduit
is typically an AEC, 11 to 14 Fr in diameter, and has the
appropriate length to allow adequate intratracheal
depth and the ability to control the proximal tip, all
while navigating a new ETT into the airway. One model
that fits this description is the Cook AEC (83 cm). Sub-
stituting an ETI for the AEC has been suggested.50 This
is certainly a viable alternative to the AEC, but the over-
all length of the ETI is inappropriate to ensure adequate
control of the proximal and distal ends of the conduit
during the reintubation procedure, if required. Moreover,
the smaller diameter 11-Fr AEC is better tolerated than
the 14-Fr model, as is the size of most ETIs. If reintuba-
tion is required over the small-diameter AEC, either a
smaller sized ETT is best to minimize the gap between
the AEC and ETT, or an Aintree intubating catheter,
which is an excellent adjunct to pass over either the
11- or 14-Fr Cook AEC. This increases its diameter to be
equivalent to the 19-Fr AEC. This upsizing of the con-
duit improves first-pass success (compared with the
smaller 11- and 14-Fr AEC or ETI) and allows a larger
ro
in
ETT to be used for reintubation.
up
pa
VAL intubation adjunct: An additional important use
un ou
for the ETI would be its invaluable role as an intuba-
rt
tion adjunct during management with VAL (with the
w
le
ith
ss
standard or hyperangulated blade). ETI use with stan-
dard-angled VAL blades is obviously useful with or
ot
without the video display capabilities. ETI use with
he
tp
the hyperangulated blade will vary in success depend-
rw
er
ing on whether you are using the steerable ETI model
is
m
versus an ETI with reasonable memory that allows the
e
is
operator to adjust ETI curvature. As previously men-
no
si
on
tioned, ensuring adequate ETI curvature to assist with
te
ETI advancement through the glottic opening with the
d.
is
hyperangulated VAL blade with the single-use, dispos-
pr
able ETI is fraught with potential failure. Practicing this
oh
technique on a mannequin or in the elective surgical
ib
setting is warranted before deploying this method in
ite
the NORA setting.
d.
Another issue related to using a hyperangled blade,
for example with the GlideScope, combined with its
proprietary hyperangulated stylet, is the variable posi-
tion of the periglottic tissues and glottic and subglottic
regions. The view may be good to excellent, yet intuba-
tion may prove difficult. Delivery of the ETT through the
glottic opening may occur with the directional vector of
force pointed anteriorly toward the cricoid ring. Once
the ETT tip is abutted against the anterior tracheal wall,
particularly when the airway is dry/desiccated and/or
the ETT tip is not preemptively lubricated, it may be
difficult to maneuver more distally. Frequently, clock-
wise or counterclockwise twisting of the ETT will allow
the tip to disengage the cricoid ring or anterior wall
and move into the distal trachea. If twisting the ETT is
not successful, consider deploying a lubricated ETI via
the ETT, as this may allow it to be advanced distally.
Upon gentle ETI advancement and meeting resistance
(with the tip against the wall), move the ETT proximally
toward you with a slight tug (<0.5-1 cm), advance the
A
was used in 1,458 encounters (overall, 6.9%). Its role in
the vast majority (n=1,313) of these encounters was as
an intubation adjunct with DL.
Most clinicians at our institution include the ETI as
a rescue adjunct with DL when a restricted or difficult
laryngeal view is revealed after one’s best laryngoscopy
attempt. Thus, “DL plus bougie” use was distributed
across a variety of laryngeal views (grades I-IIIb) with
a relatively high overall success rate of 81.8%. Moreover,
the ETI was used in a significant number of cases to
assist with advancement of the already deployed unsty-

ETI distally, possibly into the lower trachea, and then leted ETT during difficult VAL-based intubation. Its uti-
ll

advance the ETT. With accompanying VAL visualiza- lization varied during three time periods:
rig

Co

tion, this salvage maneuver can be witnessed indirectly 1. Pre–ASA complete guideline implementation
ht

py

rather than blindly. When encountering resistance to (period 1: 1990–early 1996);

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rig ed.

advancement, applying more force may work against 2. Post–ASA guidelines implementation with
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you and also lead to injury. airway adjuncts deployed and available for
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se

The second role for ETI deployment during VAL intu- elective and emergent airway interventions
rv

bation difficulty would be following ETT placement and (period 2: 1996–early 2006); and
20

stylet removal, if the ETT barely advances or retracts 3. Post–ASA guidelines with VAL
20
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above the glottic opening. The ETT tip comes to lie (period 3: late 2006 to 2019).
M
pr

just superior to or within the glottic opening. Despite As noted by the information presented in Table 3, the
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od

a good to excellent view, advancing the unstyleted ETT use of the ETI rose precipitously following our institu-
uc

may be unsuccessful. Removal of the ETT, reloading tion’s efforts to equip our STAT airway team with air-
ah in w

the ETT with the stylet and starting over is one via- way adjuncts as recommended by the ASA Guidelines
tio

on

ble option. Alternatively, passing a lubricated ETI via via the DAC and a transportable airway equipment suit-
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Pu

the indwelling ETT may allow the operator, under video case/bag. Likewise, it was added as a standard item
bl

assistance, to pass the ETI into the trachea, thus afford- to the OR anesthesia cart, whereupon its utilization
is

ing ETT advancement. rose significantly. Subsequently, in period 3, based on

ho

hi

a concerted effort by our department and the institu-

ng
le

ETI-Assisted Intubation for Emergency or tion, there was a ubiquitous deployment of advanced
or

Urgent NORA Management video technology (VAL: e.g, GlideScope) commencing

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in

The Hartford Hospital NORA management emer- in late 2006 in the OR and for the STAT anesthesia air-
up
pa

gency database (1991-2019) of nearly 21,000 intuba- way team. The subsequent use of the ETI by many indi-
un ou

tions (excluding cardiac arrests) reports that the ETI viduals contracted significantly, in favor of using VAL
rt

as a rescue adjunct for DL-achieved laryngeal views of

w

le
ith

ss

grades IIb, IIIa and IIIb both in the OR and by the STAT
anesthesia airway team (NORA setting).
ot

Table 3. Overall ETI Deployment by The successful deployment of the ETI to assist with
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tp

Time Period* tracheal intubation was, overall, 81.3% (Table 4). How-
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er

ever, this lower success rate resulted from the signifi-

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m

1990-1996 1996-2006 2006-2019 cant deployment rate and subsequent failure in grade
e
is

IIIb (down-folded or down-hanging epiglottis). Other-

no
si

ETI use, n (%) 57 (1.1) 948 (13.4) 445 (3.6)

on

wise, the success rate for grades IIb of 98% and IIIa of
te

*ETI use included conventional ETI-assisted ETT placement nearly 92% remains impressive. The ability to maneuver
d.
is

(DL) plus cases involving ETT advancement/manipulation along the leading or lateral edges of the down-hanging
pr

during VAL intubation.

epiglottis proved difficult, leading to failure to advance
oh

DL, direct laryngoscopy; ETI, endotracheal tube introducer;

ETT, endotracheal tube; VAL, video-assisted laryngoscopy into the trachea. The incidence of esophageal place-
ib

ment of the ETI was the highest for grade IIIb.

ite
d.

Table 4. Success Rate of ETI for Emergency NORA Management

View Grade I Grade IIa Grade IIb Grade IIIa Grade IIIb

Cases n (%) 9/9 (100) 6/8 (75) 125/128 (97.7) 772/845 (91.4) 155/323 (48)

N=1,313; success rate 81.3% overall.

A N E S T H E S I O L O G Y N E W S A I R WAY M A N A G E M E N T 2 0 2 0 79
 It is worth noting that placement of the ETI in the
esophagus is not equivalent to esophageal intubation
following ETT advancement over the ETI. Prior to the
hang-up test, esophageal ETT placement via the ETI in
grade IIIb views was rampant. Since actively pursuing
the use of the hang-up test for all my bougie-assisted
intubations (2003), I recall anecdotally only one case
of true esophageal intubation while using the ETI (in
retrospect, I likely retracted the ETI too much follow-
ing the hang-up test, leading to esophageal place-
ment of the ETT). Esophageal placement of the ETI,
A
managing the airway. Our emergency department staff
is aggressive in pairing VAL (with a conventional-angle
blade) and the ETI. The anesthesia-based database
logged 12 encounters with the combination of VAL and
ETI in an attempt to traverse the glottic opening with the
ETI (single-use disposable ETI combined with hyperan-
gled GlideScope blade). Each of these failed, as the oper-
ator was unable to navigate the ETI successfully around
the exaggerated curve of the VAL blade. Use in the elec-
tive OR setting may be more fruitful.
The remaining cases (VAL, n=145) involved one of two

when confronted with a grade IIIb view, remains quite scenarios: In the first, following stylet removal, the ETT
ll

high (~60%-70%), but fortunately can be discovered failed to deploy to or through the glottic opening (i.e., at
rig

Co

by the invaluable hang-up test, thus avoiding errone- the glottic level or supraglottic). The ETI was advanced
ht

py

ous ETT placement into the esophagus. In essence, the via the ETT and used to traverse the glottic opening to
s

rig ed.

incidence of esophageal placement of the ETI (alone) assist ETT advancement (18/22 successful; 82%). In the
re

remains unaffected by using the hang-up test. However, second scenario, due to the hyperangle of ETT delivery
ht
se

the hang-up test had a profound effect on nearly elimi- combined with dry mucosa/insufficient lubrication, the
rv

nating the esophageal placement of the ETT. ETT tip became impinged on the anterior wall of the sub-
20

Combining VAL with ETI is a viable pairing for glottic region at or in the vicinity of the cricoid ring. ETT
20
Re

twisting, in hopes of disengaging the ETT, failed, and

M
pr

thus ETT advancement was impeded. With the assis-

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od

tance of continuous video display, the lubricated ETI was

Table 5. Steps Required for ETT
uc

then gently advanced via the ETT to the point of meet-

ah in w

Placement Confirmation: ing resistance, at which the ETT was moved proximally
tio

on

Influence of the Hang-Up Test by 0.5 to 1 cm, whereupon the ETT could be advanced
n

Pu

(n=123; 117 successful; 95.1% success rate).

bl

Hang-Up Test Not Performed The overall incidence of esophageal intubation via
is

the ETI (14.2%, or 187/1,313 DL cases) covers all laryngeal

ho

hi

Pass ETT into the trachea or esophagus.

views. The majority of esophageal intubations—67.9%—
ng
le

Inflate cuff. using DL with ETI occurred with a grade IIIb laryngeal
or

view, and these patients had the highest esophageal

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in

Attach EtCO2 monitor. intubation rate overall, at 39.3%. Although this percent-
up
pa

Attach oxygen reservoir bag. age seems staggering, the majority of these accidental
un ou

esophageal intubations took place in the “pre–hang up”

rt

Squeeze bag, auscultate breath sounds. era. Accidental advancement of the ETI into the esoph-
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le
ith

ss

agus is an understandable consequence of ETI use, par-

Check EtCO2 for 3-6 breaths.
ticularly with Cook “restricted” and “difficult” grade IIIb
ot

Possibly remove ETT from esophagus. laryngeal views.36

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tp

Typically, ETI passage into the esophagus is without

rw

Treat desaturation, regurgitation, aspiration.

er

consequence as long as the operator detects its incor-

is
m

rect location. Passage of the ETT over the ETI into the
e

Re-attempt intubation with a fresh ETT.

is

esophagus is where the trouble begins, especially in the

no
si

Hang-Up Test Performed

on

NORA patient setting. In deciding whether or not to per-

te

form the hang-up test (Table 5), it is worth emphasiz-

d.
is

Remove ETI from esophagus or proceed with

intubation. ing the vast difference in the potentially life-threatening
pr

consequences of an esophageal intubation in the NORA

oh

EtCO2, end-tidal carbon dioxide; ETI, endotracheal tube patient, and the number of steps that must be taken to
ib

introducer; ETT, endotracheal tube confirm or refute tracheal position of the ETT. Perform-
ite

ing the simple hang-up test takes little time, but its use
d.

Table 6. Incidence of Esophageal Intubation via the ETI (ETT in Esophagus)

View Grade I Grade IIa Grade IIb Grade IIIa Grade IIIb

Cases, n (%) 0/0 0/0 3/128 (2.3) 57/845 (6.7) 127/323 (39.3)

ETI, endotracheal tube introducer; ETT, endotracheal tube

80 A N E ST H E S I O LO GY N E WS .CO M
in selected laryngeal grades (IIIa, IIIb) may provide bene-
ficial information. Does the ETI continue to advance into
the esophagus in the grade IIIb view patient (Table 6)?
Yes, but its detected misplacement should halt the unde-
sired advancement of the ETT into the esophagus.
Moving Forward While Stepping Backward
While the medical community and patients welcome
the introduction of new technology with the hope of
improved outcomes, faster recovery and other benefits,
we often see such new methods literally replacing older
A
intubation encounters over the past three decades, a
profound trend is emerging. A case with a grade IIb, IIIa
or IIIb laryngoscopic best view, previously considered
appropriate for ETI rescue, has seen an almost unani-
mous shift away from ETI-assisted intubation. Clinicians
now employ immediate transition to VAL.
Data from the Hartford Hospital NORA management
database revealed that in Period 2, clinicians used the
ETI in 59% of grade IIIa and 58% of grade IIIb cases in
its role following DL as Plan B, in order to obtain one’s
best view. After the deployment of VAL (Period 3), VAL

techniques that still have merit and value in many medi- was the overwhelming choice (Plan B) following DL. ETI
ll

cal situations. use plummeted to 14% (grade IIIa) and 10% (grade IIIb)
rig

Co

For example, laparoscopic surgery is so common that as a Plan B adjunct. Similarly, even one’s best DL view in
ht

py

resident trainees may be underexposed to an adequate grades IIa and IIb are increasingly managed by personnel
s

rig ed.

number of open techniques during their training that forgoing the ETI in favor of VAL, even when VAL is not
re

remain lifesaving and appropriate. Likewise, in airway immediately present at the bedside.
ht
se

management, a similar issue stemming from the ubiq- I have witnessed encounters in the OR where staff
rv

uitous distribution and widespread deployment of VAL would rather wait for VAL delivery to the bedside as
20

may be leading to an unintended consequence. ETI use opposed to deploying the ETI that is adjacent to their
20
Re

in combination with DL as a rescue alternative has been anesthesia machine and the patient. The literature does
M
pr

replaced in many practices by the ubiquitous presence not offer, I believe, a comparison between a DL with ETI
cM
od

and availability of VAL. One drawback to our advance- for a best view grade IIIa or IIIb and immediately aban-
ment to high-tech airway management is that it most
uc

doning the DL with ETI approach in favor of VAL. The

ah in w

certainly will hamper the education of our novice airway improved glottic visualization, in most cases, afforded by
tio

on

managers and trainees in regard to learning and gaining VAL is impressive and likely does improves patient care,
n

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competence in ETI utilization. but the delay in securing the airway may be an important
bl

Increased reliance on VAL may be potentially contrib- factor, particularly in NORA management.
is

uting to a decline in DL utilization, thereby degrading

ho

hi

DL skills. A 10-year study in South Korea noted the fre- Summary

ng
le

quency of DL decreased by 50%, from 92% to 45%, while The ETI is a valuable airway adjunct that has a long,
or

VAL increased from 8% to 55%.51 The authors reported respected history. Its multi-tasking potential, low-tech
ro
in

that first-pass success rates using DL decreased from 91% nature without batteries, portablility, low cost, ease of
up
pa

to 76% and concluded the decline likely resulted from use, short learning curve, excellent track record and
un ou

reduced DL utilization. With the reduction in DL utiliza- worldwide acceptance support its continued presence in
rt

tion, ETI bougie deployment will likely suffer. This will the airway arsenal. As Beumof spoke of AECs as a sim-
w

le

ple concept with potentially great danger,52 so the ETI

ith

ss

subsequently reduce trainees’ exposure to DL with ETI

techniques, and likely not afford the degree of experi- must be used carefully and intelligently. Several relevant
ot

ence to gain competence in its use. concepts to improve its success are key for the airway
he
tp

Although the learning curve for DL with ETI is rela- team members to practice during ETI utilization, includ-
rw
er

tively short, mastering its use likely requires a sizable ing understanding the ETI–ETT gap, adoption of a team
is
m

number of cases and differing laryngeal exposure grades approach for ETI utilization, the importance of the Coss-
e
is

to enhance one’s experience. Clinicians opt for VAL rather ham twist/ETT rotation, and the “hang-up” maneuver.
no
si
on

than grabbing a time-tested, readily available and reli- Recent advancements in airway eqiupment technology
te

able adjunct whose batteries have never failed. Follow- threaten the future viable role of the ETI as practitioners
d.
is

ing my review of thousands of elective and emergency migrate away from its deployment.
pr
oh
ib

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