Bougie trauma – it is still possible (2003)

We read with interest the recent letter (Hodzovic et al. Anaesthesia 2003; 58: 192–3) commenting on the paucity of reported cases of soft tissue trauma unambiguously caused by a multiple-use gum elastic bougie in the management of unexpected difficult intubation. As they correctly stated, so far only one such case has been reported [1]. In the same context, we want to report a critical incident involving a multiple-use gum elastic bougie that caused trauma to the airway. We believe it is a rare complication, especially when the insertion of the bougie and railroading of the tracheal tube has been successful at the first attempt. A 60-year-old, ASA II woman presented for elective gynaecological surgery. She gave a history of bronchial asthma treated with bronchodilators as required. She had received no previous anaesthetics. On airway examination, she was assessed as Mallampati grade I. After routine monitoring was established, anaesthesia was induced with fentanyl 100 µg, propofol 180 mg and rocuronium 40 mg. Bag-mask ventilation was commenced with isoflurane and oxygen 50% in nitrous oxide. At laryngoscopy, the patient was seen to have a Cormack and Lehane grade 2 view (partial view of the larynx). At the initial intubation attempt, a diagnosis of oesophageal intubation was made on the basis of lack of chest movements and no capnography trace. The tracheal tube was removed and ventilation with mask re-instituted. A second intubation was attempted using a multiple-use gum elastic bougie (Eschmann UK 15-Ch 60 cm). The bougie was advanced till the ‘hold-up’ sign was elicited (at 50 cm). No ‘clicks’ were felt as the bougie advanced. Insertion of the bougie seemed easy and an 8-mm cuffed, oral tracheal tube was railroaded successfully over it. After intubation, some fresh blood was noticed inside the tracheal tube. Correct placement was confirmed by capnography, equal chest movements and bilateral air entry into the lungs. Soon after intubation, the oxygen saturation fell to 89%. Increased resistance to ventilation and high airway pressures were experienced. Subsequently, frank blood was suctioned out of the tracheal tube. On auscultation, there was generalised wheezing on the right side. Oxygen saturations remained low (89–90%) despite increase in Fio2 to 1.0. The operation was postponed and the patient transferred to the intensive care unit (ICU) for further management. In the ICU, a chest X-ray revealed extensive opacification of the right hemithorax with some loss of volume suggestive of extensive collapse despite the tracheal tube tip lying within the trachea (Fig. 1). Fibreoptic bronchoscopy was performed and several blood clots were removed from the right main bronchus. No obvious mucosal damage to the trachea was seen. Postbronchoscopy, the oxygen saturations improved to 98%. Repeat chest X-ray 1 h later showed the right lung to be well expanded (Fig. 2). Chest X-ray revealing extensive opacification in the right hemithorax with some loss of volume suggestive of extensive collapse despite the tracheal tube tip lying within the trachea. Repeat chest X-ray 1 h later (after bronchoscopic suctioning) shows well-expanded lungs. The patient was extubated a few hours later and subsequently discharged from the ICU. A CT scan of the chest 5 days later did not show any significant focal pulmonary lesion or evidence of chest malignancy. There was no air in the mediastinum. Surgery was performed 1 month later under spinal anaesthesia without any problems. In our case, the most obvious source of the blood into the bronchus was the trauma from the multiple-use gum elastic bougie. The gum elastic bougie is useful in difficult intubation as long as the epiglottis is visible (i.e. grade 2, grade 3) at laryngoscopy [2]. It has been suggested that blind placement of the bougie can be confirmed by the ‘click’ and ‘hold-up’ signs [3]. In the United Kingdom, the multiple-use bougie is widely used by anaesthetists as the first choice method in the event of unexpected difficult intubation. Kadry and Popat reported pharyngeal wall perforation caused unambiguously by the bougie [1]. This occurred during the initial attempt of passing the multiple-use bougie. We feel that in our case it was quite unusual for a traumatic complication to happen as the insertion of the bougie and the railroading of the tracheal tube were very smooth and successful at the first attempt. In the recent letter by Hodzovic et al., the authors asked a worthwhile question: ‘How many attempts (of multiple-use bougie in the management of difficult intubation) should be recommended?’ We totally agree with the relationship between the number of attempts and traumatic complications in the use of bougies. But we also believe that it is worth considering the possibility of a traumatic complication even in an ‘easy’, first attempt, successful insertion of the gum elastic bougie. In our patient, a grade 2 view was obtained on laryngoscopy. The ‘hold-up’ sign was elicited after passing the bougie. As some part of the cords was visible, could we have avoided the trauma by not eliciting the actual ‘hold-up’ by stopping once the bougie had just passed beyond the cords?