Bougie Bonanza

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Picture of Dr. Richard Cunningham
Dr. Richard Cunningham

EM resident and aspiring intensivist with a passion for all things critical care and an unhealthy obsession with airway management. Mediocre mountain-biker and wannabe polyglot in his free time.

The Pre-brief

Resusitationists are insisting that a bougie be readily available when securing an airway. Many are even transitioning to a bougie first approach. Why do so many doctors love this tool and how do you use this tool most effectively?

Part 1: Why use a bougie?

Ever since the BEAM Trial (Bougie Use in Emergency Airway Management)1 was published in 2018, bougies have been hot, especially within the FOAM community. This single-center, randomized compared first-pass success between the bougie and an endotracheal tube and stylet among patients undergoing emergency intubation. The primary outcome was first-attempt success in patients with at least one difficult airway characteristic.

The results show that the bougie leads to higher first-pass success (98%) compared to a stylet, and the results are even more pronounced when the glottis cannot be visualized (Cormack-Lehane Grade III and IV views).

This increase in first-pass success is attributable to two factors: visual and tactile confirmation. Given its 15 French (5 mm) diameter, it is much easier to visualize passage of a bougie through the vocal folds compared to an ETT and stylet.

In the case you cannot visualize the vocal cords, you can pass the bougie blindly by tracing the posterior surface of the epiglottis or base of the tongue with the angled coudé tip (French for “bent” or “curved”) and then use tactile confirmation. This is performed with two techniques. One can use the coudé tip of the bougie to rock it along the tracheal rings and feel a clicking sensation. This is known as the “tracheal clicks” sign. You can also (gently) advance the bougie until resistance is felt either at the carina or in either mainstem. This is known as the “hold-up” sign. 

In one study, tracheal clicks were felt in 89.7% of intubations and had a 100% specificity of successful ETT placement. In the same study, the “hold-up” sign was 100% sensitive and specific for successful placement.2 What’s more, an observer (i.e. a nervous attending) can place their hand externally on the trachea and independently confirm placement when tracheal clicks are felt. Pretty darn cool!

The Debrief

  • Use of a bougie leads to higher first-pass success compared to ETT+stylet
  • The bougie allows increased visual as well as tactile confirmation of endotracheal placement
  • The “tracheal clicks” and “hold-up” signs are highly sensitive and specific markers to confirm successful placement
  • Successful placement is further confirmed with a second operator holding his or her hand over the tracheal and feeling clicks


  1. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. PMID: 29800096; PMCID: PMC6134434.
  2. Kidd JF, Dyson A, Latto IP. Successful difficult intubation. Use of the gum elastic bougie. Anaesthesia. 1988 Jun;43(6):437-8. doi: 10.1111/j.1365-2044.1988.tb06625.x. Erratum in: Anaesthesia 1988 Sep;43(9):822. PMID: 3407866.


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