Anaesthesia 2014, 69, 511–526
tip through the vocal cords. The assistant then ‘unplugs’ the pilot balloon and holds the proximal tip of the bougie, while the tracheal tube is threaded off into the trachea. The bougie is withdrawn and the tracheal tube connected to the anaesthetic breathing circuit. This technique has several advantages. It improves the speed and efficiency of the bougie manoeuvre because fewer steps are involved, and possibly requires less reliance on the skill of the assistant. From a difficult airway perspective, especially when combined with a McCoy blade, this combination is well known to improve the grade of laryngoscopy and success of intubation [4]. At our bariatric centre, it has reduced the need for elective videolaryngoscopy by 50–75% in my personal practice (unpublished observations). Beyond the bariatric population, we have used this technique in patients with limited neck movement (cervical spine injuries), maxillo- facial trauma and in some patients with limited mouth opening, for which bougie techniques have been shown to improve success [5, 6]. This technique may also avoid some of the traumatic complications of using the bougie hold-up sign [1]. Bougies are widely available globally, economical to use and familiar. Facing extinction at the hands of videolaryngoscopy, I suggest that the use of this technique may help anaesthetists retain direct laryngoscopy skills. N. Eipe The Ottawa Hospital Ottawa, Canada Email: [email protected] 516
Correspondence
No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia 2014; 69: 219–23. 2. Rai MR. The humble bougie . . . forty years and still counting? Anaesthesia 2014; 69: 199–203. 3. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94. 4. Abdullah HR, Li-Ming T, Marriott A, Wong TGL. A comparison between the Bonfils Intubation Fiberscope and McCoy Laryngoscope for tracheal intubation in patients with a simulated difficult airway. Anesthesia and Analgesia 2013; 117: 1217–20. 5. Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia 1993; 48: 630–3. 6. Combes X, Jabre P, Margenet A, et al. Unanticipated difficult airway management in the prehospital emergency setting. Prospective validation of an algorithm. Anesthesiology 2011; 114: 105–10. doi:10.1111/anae.12692
Further applications of the traffic light system I read with interest the two bougie-related articles by Marson et al. and Paul et al. in Anaesthesia, which highlighted the potential for airway trauma when using a bougie [1] and describe a simple yet effective way to reduce this risk [2]. I fully support the introduction of more intuitive markings on bougies. Paul et al. suggest that their traffic light system could be used
with other airway exchange devices and I agree, but suggest also that other applications of this system could enhance safety in other areas of anaesthesia. Unfortunately, I have been involved in a case where a guidewire was left in situ following the insertion of a central venous catheter (CVC) and I am aware of numerous other similar incidents, some with significant complications [3]. Indeed, this complication has been highlighted by the National Patient Safety Agency [4]. In anaesthesia, guidewires are used to facilitate the insertion of many devices including CVCs, arterial lines, percutaneous tracheostomies and chest drains. The markings on each guidewire vary relative to the equipment that it is used with, but are generally small and inconspicuous. A traffic light system could be applied, but a simpler system involving an obvious marking (for example, a 2-cm yellow band) at the point where further insertion would result in concealment of the wire within the line could also be used. We frequently work in stressful environments and rely on multiple stimuli to maintain safe practice; such a simple visual stimulus would be relatively cheap and easy to implement but have potential to reduce the risk of serious incidents. J. Francis Royal Glamorgan Hospital, Llantrisant, Wales Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia corres-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2014, 69, 511–526
pondence website: www.anaesthesia correspondence.com.
References 1. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia 2014; 69: 219–23. 2. Paul A, Gibson AA, Robinson ODG, Koch J. The traffic light bougie: a study of a novel safety modification. Anaesthesia 2014; 69: 214–8. 3. Gunduz Y, Vatan MB, Osken A, Cakar MA. A delayed diagnosis of a retained guidewire during central venous catheterisation: a case report and review of the literature. British Medical Journal Case Reports 19/11/2012. http:// casereports.bmj.com/content/2012/bcr2012-007064 (accessed 21/03/2014). 4. National Patient Safety Agency. Risk of harm from retained guidwires following central venous access, September 2011. http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=132829 (accessed 21/03/ 2014). doi:10.1111/anae.12703
Scalpel-bougie cricothyroidotomy We would like to propose an adjunct to the scalpel-bougie cricothyroidotomy technique described by Heard et al. in this journal [1], that supports the continued utility of bougies identified by Rai [2]. We encountered a ‘can’t intubate, can’t oxygenate’ scenario where
tissue impingement on the tip of a Portex PVC cuffed 6.0-mm tracheal tube (Smiths Medical, Hythe, UK) prevented successful advancement over a 14-F Frova bougie (Cook Medical, Bloomington, IN, USA) inserted percutaneously into the trachea. The issue was resolved when the tracheal tube was substituted for a cuffed 5.0-mm airway catheter from the Melker Emergency Cricothyrotomy Catheter Set (Cook Medical), that passed easily over the same bougie and into the trachea. The theoretical benefit of minimising any gap between the external surface of the bougie and the tracheal tube’s internal surface is that there will be less impingement by skin, subcutaneous tissue and the cricothyroid membrane when advancing the tracheal tube over the bougie. A 6.0-mm standard tracheal tube has the minimum internal diameter required to pass successfully over the 14-F Frova bougie. Tracheal tube tip design has not yet been shown to have an impact [3]. We have reproduced the technique in an animal model and feel it has merit. As can be seen in Fig. 2, minimal gap exists between the tip of the Melker catheter and the bougie. Additionally, the outer
diameter of the Melker catheter is 7.2 mm where most standard 6.0mm tracheal tubes have an outer diameter of at least 8.0 mm. A review of normal anatomy has led to the recommendation that tubes inserted via the cricothyroid membrane should not exceed an outer diameter of 8.0 mm [4]. Accidental endobronchial intubation and shallow tube placement have been reported following scalpel-bougie cricothyroidotomy with a 6.0-mm tracheal tube [5]. This is unlikely using the Melker catheter as it has a total length of 9.0 mm and is designed for placement following percutaneous cricothyroidotomy. Fixation is also relatively simple as the device has flanges through which tracheostomy tape or tracheal tube ties can be used. Disadvantages of this technique include the need for additional equipment at a time when help may be limited, and higher airway resistance due to the smaller internal diameter of the Melker catheter. A. Parameswaran L. Beckmann P. Nadarajah Royal Brisbane and Women’s Hospital Queensland, Australia Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References Figure 2 Comparison of Portex 6.0-mm tracheal tube and Melker 5.0-mm airway catheter over a bougie. © 2014 The Association of Anaesthetists of Great Britain and Ireland
1. Heard AMB, Green RJ, Eakins P. The formulation and introduction of a can’t intubate, 517
tip through the vocal cords. The assistant then ‘unplugs’ the pilot balloon and holds the proximal tip of the bougie, while the tracheal tube is threaded off into the trachea. The bougie is withdrawn and the tracheal tube connected to the anaesthetic breathing circuit. This technique has several advantages. It improves the speed and efficiency of the bougie manoeuvre because fewer steps are involved, and possibly requires less reliance on the skill of the assistant. From a difficult airway perspective, especially when combined with a McCoy blade, this combination is well known to improve the grade of laryngoscopy and success of intubation [4]. At our bariatric centre, it has reduced the need for elective videolaryngoscopy by 50–75% in my personal practice (unpublished observations). Beyond the bariatric population, we have used this technique in patients with limited neck movement (cervical spine injuries), maxillo- facial trauma and in some patients with limited mouth opening, for which bougie techniques have been shown to improve success [5, 6]. This technique may also avoid some of the traumatic complications of using the bougie hold-up sign [1]. Bougies are widely available globally, economical to use and familiar. Facing extinction at the hands of videolaryngoscopy, I suggest that the use of this technique may help anaesthetists retain direct laryngoscopy skills. N. Eipe The Ottawa Hospital Ottawa, Canada Email: [email protected] 516
Correspondence
No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia 2014; 69: 219–23. 2. Rai MR. The humble bougie . . . forty years and still counting? Anaesthesia 2014; 69: 199–203. 3. Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004; 59: 675–94. 4. Abdullah HR, Li-Ming T, Marriott A, Wong TGL. A comparison between the Bonfils Intubation Fiberscope and McCoy Laryngoscope for tracheal intubation in patients with a simulated difficult airway. Anesthesia and Analgesia 2013; 117: 1217–20. 5. Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia 1993; 48: 630–3. 6. Combes X, Jabre P, Margenet A, et al. Unanticipated difficult airway management in the prehospital emergency setting. Prospective validation of an algorithm. Anesthesiology 2011; 114: 105–10. doi:10.1111/anae.12692
Further applications of the traffic light system I read with interest the two bougie-related articles by Marson et al. and Paul et al. in Anaesthesia, which highlighted the potential for airway trauma when using a bougie [1] and describe a simple yet effective way to reduce this risk [2]. I fully support the introduction of more intuitive markings on bougies. Paul et al. suggest that their traffic light system could be used
with other airway exchange devices and I agree, but suggest also that other applications of this system could enhance safety in other areas of anaesthesia. Unfortunately, I have been involved in a case where a guidewire was left in situ following the insertion of a central venous catheter (CVC) and I am aware of numerous other similar incidents, some with significant complications [3]. Indeed, this complication has been highlighted by the National Patient Safety Agency [4]. In anaesthesia, guidewires are used to facilitate the insertion of many devices including CVCs, arterial lines, percutaneous tracheostomies and chest drains. The markings on each guidewire vary relative to the equipment that it is used with, but are generally small and inconspicuous. A traffic light system could be applied, but a simpler system involving an obvious marking (for example, a 2-cm yellow band) at the point where further insertion would result in concealment of the wire within the line could also be used. We frequently work in stressful environments and rely on multiple stimuli to maintain safe practice; such a simple visual stimulus would be relatively cheap and easy to implement but have potential to reduce the risk of serious incidents. J. Francis Royal Glamorgan Hospital, Llantrisant, Wales Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia corres-
© 2014 The Association of Anaesthetists of Great Britain and Ireland
Correspondence
Anaesthesia 2014, 69, 511–526
pondence website: www.anaesthesia correspondence.com.
References 1. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia 2014; 69: 219–23. 2. Paul A, Gibson AA, Robinson ODG, Koch J. The traffic light bougie: a study of a novel safety modification. Anaesthesia 2014; 69: 214–8. 3. Gunduz Y, Vatan MB, Osken A, Cakar MA. A delayed diagnosis of a retained guidewire during central venous catheterisation: a case report and review of the literature. British Medical Journal Case Reports 19/11/2012. http:// casereports.bmj.com/content/2012/bcr2012-007064 (accessed 21/03/2014). 4. National Patient Safety Agency. Risk of harm from retained guidwires following central venous access, September 2011. http://www.nrls.npsa.nhs.uk/resources/ ?entryid45=132829 (accessed 21/03/ 2014). doi:10.1111/anae.12703
Scalpel-bougie cricothyroidotomy We would like to propose an adjunct to the scalpel-bougie cricothyroidotomy technique described by Heard et al. in this journal [1], that supports the continued utility of bougies identified by Rai [2]. We encountered a ‘can’t intubate, can’t oxygenate’ scenario where
tissue impingement on the tip of a Portex PVC cuffed 6.0-mm tracheal tube (Smiths Medical, Hythe, UK) prevented successful advancement over a 14-F Frova bougie (Cook Medical, Bloomington, IN, USA) inserted percutaneously into the trachea. The issue was resolved when the tracheal tube was substituted for a cuffed 5.0-mm airway catheter from the Melker Emergency Cricothyrotomy Catheter Set (Cook Medical), that passed easily over the same bougie and into the trachea. The theoretical benefit of minimising any gap between the external surface of the bougie and the tracheal tube’s internal surface is that there will be less impingement by skin, subcutaneous tissue and the cricothyroid membrane when advancing the tracheal tube over the bougie. A 6.0-mm standard tracheal tube has the minimum internal diameter required to pass successfully over the 14-F Frova bougie. Tracheal tube tip design has not yet been shown to have an impact [3]. We have reproduced the technique in an animal model and feel it has merit. As can be seen in Fig. 2, minimal gap exists between the tip of the Melker catheter and the bougie. Additionally, the outer
diameter of the Melker catheter is 7.2 mm where most standard 6.0mm tracheal tubes have an outer diameter of at least 8.0 mm. A review of normal anatomy has led to the recommendation that tubes inserted via the cricothyroid membrane should not exceed an outer diameter of 8.0 mm [4]. Accidental endobronchial intubation and shallow tube placement have been reported following scalpel-bougie cricothyroidotomy with a 6.0-mm tracheal tube [5]. This is unlikely using the Melker catheter as it has a total length of 9.0 mm and is designed for placement following percutaneous cricothyroidotomy. Fixation is also relatively simple as the device has flanges through which tracheostomy tape or tracheal tube ties can be used. Disadvantages of this technique include the need for additional equipment at a time when help may be limited, and higher airway resistance due to the smaller internal diameter of the Melker catheter. A. Parameswaran L. Beckmann P. Nadarajah Royal Brisbane and Women’s Hospital Queensland, Australia Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References Figure 2 Comparison of Portex 6.0-mm tracheal tube and Melker 5.0-mm airway catheter over a bougie. © 2014 The Association of Anaesthetists of Great Britain and Ireland
1. Heard AMB, Green RJ, Eakins P. The formulation and introduction of a can’t intubate, 517
