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The role of tracheal tube introducers and stylets in current airway management

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Abstract

Tracheal tube introducers and stylets are highly successful devices for the management of various airway scenarios. Their first-line use is advocated in many difficult airway algorithms. Although they have been used for decades, the shape and design of introducers and stylets as well as their patterns of use are constantly evolving. Our purpose is to provide the clinician with an update on these different devices. We performed a systematic literature search from 2005 until May 2015, without language restrictions. The two authors independently retrieved all studies with the keywords “bougie”, “gum elastic bougie”, “stylet”, “airway management”, “tracheal tube introducer” and “extubation catheter”. Our search did yield mostly observational and retrospective studies with small case numbers. The data was synthesized into a narrative review to provide the clinician with an update on the characteristics, indications and techniques of use as well as the dangers of different intubation aids. Today, numerous tracheal tube introducers and stylets exist with different indications, ranging from general to specific situations. Anesthetists should be familiar with the different devices, their characteristics and indications in order to use the right device at the right time in the right way.

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References

  1. Hove LD, Steinmetz J, Christoffersen JK, Moller A, Nielsen J, Schmidt H. Analysis of deaths related to anesthesia in the period 1996–2004 from closed claims registered by the Danish Patient Insurance Association. Anesthesiology. 2007;106(4):675–80. doi:10.1097/01.anes.0000264749.86145.e5.

    Article  PubMed  Google Scholar 

  2. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33–9.

    Article  PubMed  Google Scholar 

  3. Cook TM, Woodall N, Frerk C, Fourth National Audit P. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society Part 1: anaesthesia. Br J Anaesth. 2011;106(5):617–31. doi:10.1093/bja/aer058.

    Article  CAS  PubMed  Google Scholar 

  4. Stasiuk RB. Improving styletted oral tracheal intubation: rational use of the OTSU. Can J Anaesth. 2001;48(9):911–8. doi:10.1007/BF03017359.

    Article  CAS  PubMed  Google Scholar 

  5. Kidd JF, Dyson A, Latto IP. Successful difficult intubation. Use of the gum elastic bougie. Anaesthesia. 1988;43(6):437–8.

    Article  CAS  PubMed  Google Scholar 

  6. Difficult Airway Society. Unanticipated difficult tracheal intubation during routine induction of anaesthesia in an adult patient. 2015. http://www.das.uk.com/guidelines/das_intubation_guidelines.

  7. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A, American Society of Anesthesiologists Task Force on Management of the Difficult A. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–70. doi:10.1097/ALN.0b013e31827773b2.

    Article  PubMed  Google Scholar 

  8. Hartmannsgruber MW, Rosenbaum SH. Safer endotracheal tube exchange technique. Anesthesiology. 1998;88(6):1683.

    Article  CAS  PubMed  Google Scholar 

  9. Mort TC. Tracheal tube exchange: feasibility of continuous glottic viewing with advanced laryngoscopy assistance. Anesth Analg. 2009;108(4):1228–31. doi:10.1213/ane.0b013e3181990a82.

    Article  PubMed  Google Scholar 

  10. Lambotte P, Menu H, Guermouche T, Boufflers E, Ferri J, Krivosic-Horber R. Intraoperative exchange of the endotracheal tube using the Cook C-CAE airway exchange catheter. Ann Fr Anesth Reanim. 1998;17(10):1235–8.

    Article  CAS  PubMed  Google Scholar 

  11. Biro P, Priebe HJ. Staged extubation strategy: is an airway exchange catheter the answer? Anesth Analg. 2007;105(5):1182–5. doi:10.1213/01.ane.0000286234.96551.67.

    Article  PubMed  Google Scholar 

  12. Batuwitage B, McDonald A, Nishikawa K, Lythgoe D, Mercer S, Charters P. Comparison between bougies and stylets for simulated tracheal intubation with the C-MAC D-blade videolaryngoscope. Eur J Anaesthesiol. 2014;. doi:10.1097/EJA.0000000000000070.

    Google Scholar 

  13. Nielsen AA, Hope CB, Bair AE. GlideScope videolaryngoscopy in the simulated difficult airway: bougie vs standard stylet. West J Emerg Med. 2010;11(5):426–31.

    PubMed  PubMed Central  Google Scholar 

  14. Wadman M, Nicholas TA, Bernhagen MA, Kuper GM, Miljkovic N, Schmidt S, Massignan J, Boedeker BH. Use of a malleable bougie and curved forceps with videolaryngoscopy in airway management training in a cadaver model: a pilot study. Stud Health Technol Inform. 2012;173:537–9.

    PubMed  Google Scholar 

  15. Macintosh RR. An aid to oral intubation. BMJ. 1949;1:28.

    Google Scholar 

  16. Henderson JJ. Development of the ‘gum-elastic bougie’. Anaesthesia. 2003;58(1):103–4.

    Article  CAS  PubMed  Google Scholar 

  17. Nolan JP, Wilson ME. An evaluation of the gum elastic bougie. Intubation times and incidence of sore throat. Anaesthesia. 1992;47(10):878–81.

    Article  CAS  PubMed  Google Scholar 

  18. Maclean J, Tripathy D, Parthasarathy S, Ravishankar M. Comparative evaluation of gum-elastic bougie and introducer tool as aids in positioning of ProSeal laryngeal mask airway in patients with simulated restricted neck mobility. Indian J Anaesth. 2013;57(3):248–252.

  19. Brimacombe J, Keller C. Gum elastic bougie-guided insertion of the LMA-ProSeal in occult tonsillar hypertrophy. Can J Anaesth. 2004;51(8):859.

    Article  PubMed  Google Scholar 

  20. Paul A, Gibson AA, Robinson OD, Koch J. The traffic light bougie: a study of a novel safety modification. Anaesthesia. 2014;69(3):214–8. doi:10.1111/anae.12522.

    Article  CAS  PubMed  Google Scholar 

  21. Campbell J. Traffic light bougie: what is the safe zone? Anaesthesia. 2014;69(5):514–5. doi:10.1111/anae.12699.

    Article  CAS  PubMed  Google Scholar 

  22. Evans H, Hodzovic I, Latto IP. Tracheal tube introducers: choose and use with care. Anaesthesia. 2010;65(8):859. doi:10.1111/j.1365-2044.2010.06432.x.

    Article  CAS  PubMed  Google Scholar 

  23. Sorbello M, Frova G. Frova introducer: neither a stylet nor simply an introducer. Anaesthesia. 2008;63(9):1010–1. doi:10.1111/j.1365-2044.2008.05661_1.x.

    Article  CAS  PubMed  Google Scholar 

  24. Muallem M. Endotracheal tube introducer: an aid for the difficult airway. Middle East J Anaesthesiol. 2000;15(6):687–92.

    CAS  PubMed  Google Scholar 

  25. Muallem MK, Azar MS, Gerges FJ, Nasr VG, Baraka A. Muallem endo-tracheal tube introducer: (METTI)–an aid for the difficult airway. Middle East J Anaesthesiol. 2005;18(2):385–9.

    PubMed  Google Scholar 

  26. Mort TC, Braffett BH. Conventional versus video laryngoscopy for tracheal tube exchange: glottic visualization, success rates, complications, and rescue alternatives in the high-risk difficult airway patient. Anesth Analg. 2015;121(2):440–8. doi:10.1213/ANE.0000000000000825.

    Article  PubMed  Google Scholar 

  27. McLean S, Lanam CR, Benedict W, Kirkpatrick N, Kheterpal S, Ramachandran SK. Airway exchange failure and complications with the use of the Cook Airway Exchange Catheter®: a single center cohort study of 1177 patients. Anesth Analg. 2013;117(6):1325–7. doi:10.1213/ANE.0b013e3182a7cd3d.

    Article  PubMed  Google Scholar 

  28. Choi EK, Kim JE, Soh SR, Kim CK, Park WK. Usefulness of a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome -A case report. Korean J Anesthesiol. 2013;64(2):168–71. doi:10.4097/kjae.2013.64.2.168.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Atherton DP, O’Sullivan E, Lowe D, Charters P. A ventilation-exchange bougie for fibreoptic intubations with the laryngeal mask airway. Anaesthesia. 1996;51(12):1123–6.

    Article  CAS  PubMed  Google Scholar 

  30. Heard AM, Lacquiere DA, Riley RH. Manikin study of fibreoptic-guided intubation through the classic laryngeal mask airway with the Aintree intubating catheter vs the intubating laryngeal mask airway in the simulated difficult airway. Anaesthesia. 2010;65(8):841–7. doi:10.1111/j.1365-2044.2010.06412.x.

    Article  CAS  PubMed  Google Scholar 

  31. Malcharek MJ, Rockmann K, Zumpe R, Sorge O, Winter V, Sablotzki A, Schneider G. Comparison of Aintree and Fastrach techniques for low-skill fibreoptic intubation in patients at risk of secondary cervical injury: a randomised controlled trial. Eur J Anaesthesiol. 2014;31(3):153–8. doi:10.1097/EJA.0b013e328365ae49.

    Article  PubMed  Google Scholar 

  32. Cook TM, Seller C, Gupta K, Thornton M, O’Sullivan E. Non-conventional uses of the Aintree Intubating Catheter in management of the difficult airway. Anaesthesia. 2007;62(2):169–74. doi:10.1111/j.1365-2044.2006.04909.x.

    Article  CAS  PubMed  Google Scholar 

  33. Metzner J, Posner KL, Lam MS, Domino KB. Closed claims’ analysis. Best Pract Res Clin Anaesthesiol. 2011;25(2):263–76. doi:10.1016/j.bpa.2011.02.007.

    Article  PubMed  Google Scholar 

  34. Difficult Airway Society Extubation Guidelines G, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012;67(3):318–40. doi:10.1111/j.1365-2044.2012.07075.x.

    Article  Google Scholar 

  35. Levitan RM, Pisaturo JT, Kinkle WC, Butler K, Everett WW. Stylet bend angles and tracheal tube passage using a straight-to-cuff shape. Acad Emerg Med. 2006;13(12):1255–8. doi:10.1197/j.aem.2006.06.058.

    Article  PubMed  Google Scholar 

  36. McElwain J, Malik MA, Harte BH, Flynn NH, Laffey JG. Determination of the optimal stylet strategy for the C-MAC videolaryngoscope. Anaesthesia. 2010;65(4):369–78. doi:10.1111/j.1365-2044.2010.06245.x.

    Article  CAS  PubMed  Google Scholar 

  37. Schoettker P. The orotracheal tube dance. Eur J Anaesthesiol. 2015;32(6):443–4. doi:10.1097/EJA.0000000000000134.

    Article  PubMed  Google Scholar 

  38. Rohsbach C, Wirth S, Lenz K, Priebe H. Survey on the current management of rapid sequence induction in Germany. Minerva Anestesiol. 2013;79(7):716–26.

    CAS  PubMed  Google Scholar 

  39. Ridgway S, Hodzovic I, Woollard M, Latto IP. Prehospital airway management in ambulance services in the United Kingdom. Anaesthesia. 2004;59(11):1091–4. doi:10.1111/j.1365-2044.2004.03965.x.

    Article  CAS  PubMed  Google Scholar 

  40. Jones PM, Loh FL, Youssef HN, Turkstra TP. A randomized comparison of the GlideRite® Rigid Stylet to a malleable stylet for orotracheal intubation by novices using the GlideScope®. Can J Anaesth. 2011;58(3):256–61. doi:10.1007/s12630-010-9440-z.

    Article  PubMed  Google Scholar 

  41. Mahajan R, Shafi F, Sharma A. Use of schroeder directional stylet to enhance navigability during nasotracheal intubation. J Anesth. 2010;24(1):150–1. doi:10.1007/s00540-009-0838-0.

    Article  PubMed  Google Scholar 

  42. Xue FS, Liao X, Liu JH, Yuan YJ, Wang Q. Performance of the GlideRite® Rigid Stylet and malleable stylet for tracheal intubation by novices using the GlideScope® videolaryngoscope. Can J Anaesth. 2011;58(7):660. doi:10.1007/s12630-011-9503-9.

    Article  PubMed  Google Scholar 

  43. Lomax SL, Johnston KD, Marfin AG, Yentis SM, Kathawaroo S, Popat MT. Nasotracheal fibreoptic intubation: a randomised controlled trial comparing the GlideRite® (Parker-Flex® Tip) nasal tracheal tube with a standard pre-rotated nasal RAE tracheal tube. Anaesthesia. 2011;66(3):180–4. doi:10.1111/j.1365-2044.2011.06621.x.

    Article  CAS  PubMed  Google Scholar 

  44. Detave M, Shiniara M, Leborgne JM. Use of Eschmann’s gum elastic bougie in difficult orotracheal intubation, an audit over eight years of clinical practice. Ann Fr Anesth Reanim. 2008;27(2):154–7. doi:10.1016/j.annfar.2007.11.006.

    Article  CAS  PubMed  Google Scholar 

  45. Jabre P, Combes X, Leroux B, Aaron E, Auger H, Margenet A, Dhonneur G. Use of gum elastic bougie for prehospital difficult intubation. Am J Emerg Med. 2005;23(4):552–5.

    Article  PubMed  Google Scholar 

  46. Marson BA, Anderson E, Wilkes AR, Hodzovic I. Bougie-related airway trauma: dangers of the hold-up sign. Anaesthesia. 2014;69(3):219–23. doi:10.1111/anae.12534.

    Article  CAS  PubMed  Google Scholar 

  47. Hodzovic I, Latto IP, Wilkes AR, Hall JE, Mapleson WW. Evaluation of Frova, single-use intubation introducer, in a manikin. Comparison with Eschmann multiple-use introducer and Portex single-use introducer. Anaesthesia. 2004;59(8):811–6. doi:10.1111/j.1365-2044.2004.03809.x.

    Article  CAS  PubMed  Google Scholar 

  48. Kadry M, Popat M. Pharyngeal wall perforation: an unusual complication of blind intubation with a gum elastic bougie. Anaesthesia. 1999;54(4):404–5.

    Article  CAS  PubMed  Google Scholar 

  49. Arndt GA, Cambray AJ, Tomasson J. Intubation bougie dissection of tracheal mucosa and intratracheal airway obstruction. Anesth Analg. 2008;107(2):603–4. doi:10.1213/ane.0b013e318176fe36.

    Article  PubMed  Google Scholar 

  50. Sahin M, Anglade D, Buchberger M, Jankowski A, Albaladejo P, Ferretti GR. Case reports: iatrogenic bronchial rupture following the use of endotracheal tube introducers. Can J Anaesth. 2012;59(10):963–7. doi:10.1007/s12630-012-9763-z.

    Article  PubMed  Google Scholar 

  51. Staikou C, Mani AA, Fassoulaki AG. Airway injury caused by a Portex single-use bougie. J Clin Anesth. 2009;21(8):616–7. doi:10.1016/j.jclinane.2009.03.006.

    Article  PubMed  Google Scholar 

  52. Smith BL. Haemopneumothorax following bougie-assisted tracheal intubation. Anaesthesia. 1994;49(1):91.

    Article  CAS  PubMed  Google Scholar 

  53. Magboul MM, Joel S. The video laryngoscopes blind spots and possible lingual nerve injury by the Gliderite rigid stylet–case presentation and review of literature. Middle East J Anesthesiol. 2010;20(6):857–60.

    PubMed  Google Scholar 

  54. Cooper RM. Complications associated with the use of the GlideScope videolaryngoscope. Can J Anaesth. 2007;54(1):54–7.

    Article  PubMed  Google Scholar 

  55. Choo MK, Yeo VS, See JJ. Another complication associated with videolaryngoscopy. Can J Anaesth. 2007;54(4):322–4. doi:10.1007/BF03022782.

    Article  PubMed  Google Scholar 

  56. Chalhoub V, Richa F, El-Rassi I, Dagher C, Yazbeck P. Pulmonary migration of a fragment of plastic coating sheared from a stylet. J Emerg Med. 2013;44(6):1097–100. doi:10.1016/j.jemermed.2012.11.004.

    Article  PubMed  Google Scholar 

  57. Schaffranietz L, Graz F, Tamke A. Intratracheal foreign body caused by a sheared endotracheal intubation stylet. Der Anaesthesist. 2009;58(12):1223–5. doi:10.1007/s00101-009-1641-x.

    Article  CAS  PubMed  Google Scholar 

  58. Gardner M, Janokwski S. Detachment of the tip of a gum-elastic bougie. Anaesthesia. 2002;57(1):88–9.

    CAS  PubMed  Google Scholar 

  59. Axe R, Middleditch A, Kelly FE, Batchelor TJ, Cook TM. Macroscopic barotrauma caused by stiff and soft-tipped airway exchange catheters: an in vitro case series. Anesth Analg. 2015;120(2):355–61. doi:10.1213/ANE.0000000000000569.

    Article  PubMed  Google Scholar 

  60. Miller DM, Youkhana I, Karunaratne WU, Pearce A. Presence of protein deposits on ‘cleaned’ re-usable anaesthetic equipment. Anaesthesia. 2001;56(11):1069–72.

    Article  CAS  PubMed  Google Scholar 

  61. Cupitt JM. Microbial contamination of gum elastic bougies. Anaesthesia. 2000;55(5):466–8.

    Article  CAS  PubMed  Google Scholar 

  62. Rowley E, Dingwall R. The use of single-use devices in anaesthesia: balancing the risks to patient safety. Anaesthesia. 2007;62(6):569–74. doi:10.1111/j.1365-2044.2007.04995.x.

    Article  CAS  PubMed  Google Scholar 

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Sina Grape and Patrick Schoettker do not have any external funding.

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Correspondence to Patrick Schoettker.

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Patrick Schoettker has participated in the development of the VBM S-Guide, Malleable Intubating Guide (www.vbm-medical.com).

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Grape, S., Schoettker, P. The role of tracheal tube introducers and stylets in current airway management. J Clin Monit Comput 31, 531–537 (2017). https://doi.org/10.1007/s10877-016-9879-8

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