During direct laryngoscopy, a Cormack-Lehane grade 2b view is obtained (only posterior glottic structures visible, arytenoids seen). The anaesthetist decides to use a bougie (gum elastic bougie). The CORRECT technique for bougie-assisted intubation is to:

• A Insert the bougie under direct vision until the black marker reaches the incisors, then railroad the tube over it
• B Insert the bougie blindly through the nose and confirm with capnography before oral intubation
• C Pass the bougie through the glottis only after a stylet has been used to obtain a grade 1 view
• D Advance the bougie anteriorly and superiorly until clicks or hold-up is felt at a bronchial level, then railroad the ETT over the bougie ✓

Explanation

The bougie is passed under the epiglottis and advanced anteriorly into the trachea until tracheal clicks (bougie bumping against tracheal rings) or hold-up (bougie catching in a small bronchus) is felt, confirming tracheal rather than oesophageal placement. The ETT is then railroaded over it. The black marker method is not standard practice. Tracheal clicks and hold-up are the classic confirmatory signs described in standard anaesthetic texts and difficult airway guidelines.

Reference: Difficult Airway Society Guidelines / BJA Education

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Written and medically reviewed by the StethoPrep medical team.