The bougie is flexible but has some shape retention.  It is best handled by keeping the distal half as straight as possible, inserting the upturned distal Coude tip under the epiglottis or, preferably, above the interarytenoid notch if it is visible.The bougie is not a “heat seeking missile”, i.e., it does not “find” the trachea automatically;laryngeal landmarks, i.e., the epiglottis at a minimum, or preferably the posterior cartilages must be sighted to place the bougie in the trachea. Some operators grip the bougie as a pencil, place the device with their right hand, and retain their laryngoscope in the left,allowing an assistant to railroad a tracheal tube into proper position. Another technique, is a one-handed grip of the tube and bougie, which Dr. Levitan first saw during a trip to Dr. Paul Baker’s conference in Auckland NZ.

The “Kiwi grip” of the bougie and tracheal tube (shown with a Parker tube)

1) The narrow diameter (5 mm) provides easier target visualization compared with a cuffed tracheal tube. It has a small upturned distal tip and can be given a curved upward shape to facilitate passage under the epiglottis.

2) The tip is felt bouncing off the tracheal rings in 65-90% of cases, and it stops advancing at 24-40 cm because of the narrowing airways. Occassionally, the tip will impinge on a tracheal ring and stop.; slight clockwise rotation rotates the tip off of the trachea ring permitting insertion . The device has markings to identify depth. It is essential that the clinician note the location of the markings and the orientation of the upturned tip as a bougie is inserted. Minor rotational changes at the proximal end of the bougie can cause a significant change in the orientation and location of the tip. For successful placement in cases of epiglottis-only views, the upturned distal tip must be kept midline and immediately underneath the epiglottis.

1) Passing a tube off a bougie (or flexible scope within trachea) is different from a tracheal tube tip catching the tracheal rings. Problem here is at laryngeal inlet, not tracheal rings.

2) Gap between devices (difference between outer diameter of bougie and inner diameter of tube) creates mechanical problem with tube advancement at 14-18 cm when coming off of a bougie or fiberscope (laryngeal inlet).

3) Counter-clockwise rotation turns bevel inferiorly. Tip passes under epiglottis, gap is closed, and tube enters larynx symmetrically.

With a Parker Flex-Tip tracheal tube (shown at left) this gap problem is eliminated because of the symmetric ski-tip shaped design of the tube.