Kiwi grip bougie ET insertion?

[Tigger]

What advantage does this offer over the traditional technique of placing the bougie and then sliding the ETT onto it?

I find it easier to exchange the tube, seems to save a step. And as other's have said it provides a better grip to manipulate the bougie.

I guess anything that helps you get the tube in isn't necessarily a bad thing, and anything that optimizes your chances is useful to a point. However, your first attempt is not always your best attempt - sometimes you can't see an anatomical problem until you actually visualize it, and then perhaps make an adjustment so that your 2nd attempt is your best attempt.

What I really like to see with my students is for them to learn how to intubate properly without all the crutches and gimmicks that people keep coming up with. There is a growing concern that many folks, sadly including anesthesia professionals, want to use a VL for every intubation and will lose their basic intubation skills. I agree, and I think that's wrong way to go about doing it. Learn it the right way first before trying to take shortcuts or the easy way out. This video not only uses a VL, but this "kiwi bougie" technique, which is pretty much overkill and takes a lot more time to set up and do. There will be times when you don't have your VL, or your bougie, or you'll use them and they won't be helpful. Hey, I'm a huge fan of our GlideScopes - but they are not the be-all and end-all of intubation aids, and neither are bougies, and neither are bougies with a "kiwi grip".

I agree about the VL. There are times when the current technology is overmatched (secretions, etc.). I'm not sure I view the bougie as a crutch though. If you go in and find yourself with a less than excellent view, you can often still pass the bougie. If you don't have the bougie already in place, that's not happening and you need a second attempt, which may increase the likelihood of a poor outcome. If you do have a great view, great. Things are even easier. I suppose it's possible to not have one available, though we two in the bag and one in the ambulance and I at least check for them to be there. Odds are, if I don't have a bougie, I don't have any airway equipment at all.

Most anyone who has been practicing for more than say, 10 years or so probably didn't have US available during their initial training and their first few years of practice.

I learned landmarks and practiced them on manikins, but every actual CL I've done was with US. I don't think I've seen a CL done without US in years. I'm sure plenty of folks still do, but in many facilities it is policy to use US.

Most of the central lines I saw placed in the OR were done with landmarks only, this was with both the surgeons and anesthesiologist.

And of note, the the anesthesia staff that provide for OR time and mentoring for our system (initial paramedic education and then later an RSI course) were all about us using a bougie, and several of them were very quick to dispel the notion that it's somehow cheating.

 

[Carlos Danger]

I don't think the bougie is a crutch at all. I feel naked if I don't have one nearby when I'm putting people to sleep. I don't think VL is, either - it has basically revolutionized difficult airway management in a short amount of time. As I said before, part of me agrees that there's a lot of value in everyone still working to keep strong, basic DL skills that rely as little as possible on adjuncts, but I also do think the importance of that will lessen as time goes on and the technology improves, just like the way that US has become (or at least is quickly becoming) the standard for PNB's and CL's and probably soon, neuraxial blocks.

I think for people who intubate only occasionally (i.e, pretty much anyone who intubates but doesn't work in the OR), and especially for those whose intubations tend to be in more difficult circumstances (paramedics), finding ways to stack the deck in favor of first-pass success is perfectly appropriate.

Now I'll admit, this kiwi-grip thing looks a little gimmicky to me, which is why I asked what advantage it offers. But if folks really think it makes it easier to them to pass the tube, thats all that matters. I'm certainly not going to argue against it.

One thing that I do think folks should be really careful relying on is passive oxygenation. Passive airway obstruction is very common, even in many non-obese patients, so there are many patients that it simply won't work in. It will work in some, and in some cases may make a real difference. So using it is fine, but relying on it, expecting and counting on it to make a big difference, is not.

 

[Brandon O]

Now I'll admit, this kiwi-grip thing looks a little gimmicky to me, which is why I asked what advantage it offers. But if folks really think it makes it easier to them to pass the tube, thats all that matters. I'm certainly not going to argue against it.

I think it's meant to allow immediate intubation once you pass the bougie, without the need for helpers who aren't always present or may not know your shtick.

One thing that I do think folks should be really careful relying on is passive oxygenation. Passive airway obstruction is very common, even in many non-obese patients, so there are many patients that it simply won't work in. It will work in some, and in some cases may make a real difference. So using it is fine, but relying on it, expecting and counting on it to make a big difference, is not.

Surely in most cases elevation of the blade during laryngoscopy will clear said obstruction by prognathing the jaw?

 

[StCEMT]

The one thing I noticed with the kiwi grip vs stylet is that I have better control, even when I wasn't getting an ideal view. In lab and OR I still practice with the methods/tools that I do not prefer or like as much, but the kiwi grip gets my vote for any field intubation I will have to do. I won't have the luxury of a VL at the company I work at, so I will use every tool I have to make my job easier. Hell, I know a medic who is awesome at digital intubations. Might as well know lots of ways to do it, just to have it in the tool box.

 

[Carlos Danger]

I think it's meant to allow immediate intubation once you pass the bougie, without the need for helpers who aren't always present or may not know your shtick.

That was my first thought. But in the video that was posted, he stressed how you should use two people anyway so that you can maintain visualization until the cuff is past the cords.

Surely in most cases elevation of the blade during laryngoscopy will clear said obstruction by prognathing the jaw?

The problem that I see with this technique is that if the airway is unobstructed, then you will usually have no problem masking or visualizing the airway. It's the times that you have a hard time gaining visualization that you need the advantage most, and those are exactly the times that it is least likely to work well. I don't doubt that it works well sometimes and is thus worth using, I just don't think it should be relied upon, as in giving extra confidence to try something that you know might get you in over your head.

It's like the emergency brake in your car. It makes good sense to ensure it is there and working in case you ever need it, but that shouldnt give you the confidence to go driving in the mountains knowing your main brakes were in poor repair.

 

[Brandon O]

The problem that I see with this technique is that if the airway is unobstructed, then you will usually have no problem masking or visualizing the airway. It's the times that you have a hard time gaining visualization that you need the advantage most, and those are exactly the times that it is least likely to work well.

Wouldn't you say it's rather unusual to have COMPLETE obstruction of the airway, even in difficult cases? Difficulty arises from difficult masking, poor visualization, difficulty passing the tube, etc not usually because the glottis is totally sealed (obviously I mean during laryngoscopy, not lying on the side of the road prior to any airway maneuvers). Even if you're having trouble getting the plastic into the hole I would imagine it still typically has at least some patency. (Unless there's obstruction in the nasopharynx -- so an NPA or two might be smart.)

 

[jwk]

Random question for you and jwk. Do anesthesiology staff still know how to put in central lines by landmark? Can they do it without landmarks? Just pondering an idea I have about resus and putting in a PAC via IJ cordis, do all staff still know how to do that?

I don't do central lines at my current gig, but I have probably put in a couple thousand central lines, including PA catheters, all without U/S guidance and going strictly by landmarks. With an IJ approach, I had zero incidence of pneumothorax, and never put a dilator/cordis in the carotid (although I have seen someone else do it and it ain't pretty). U/S guidance is almost standard of care, although I see a lot of subclavians still being placed without U/S.

 

[SeeNoMore]

I don't use this technique , but I do use the bougie on every DL tube. I agree that the vast majority of the time it is not necessary, but I feel that when an airway comes along where it would be useful I am already accustomed to using it. Usually this is not an airway with some type of obstruction, but one where the view is marginal even with positioning and ELM. Typically in these cases I have little difficulty because the bougie is easy to manipulate and has a narrow profile.

 

[Carlos Danger]

Wouldn't you say it's rather unusual to have COMPLETE obstruction of the airway, even in difficult cases?

No, I wouldn't say it's unusual at all. If you take a large sample of the population, lay them flat, and give them a moderate to heavy dose of sedation, probably around half will obstruct their airway completely or at least to the point that they severely hypoventilate. Among moderately to severely obese individuals, it might be closer to 90% or more who obstruct.

For most of those, you can easily remedy the obstruction with positioning or a chin lift, but doing that takes recognition, manipulation of the head and neck, and it may require a dedicated person to maintain and may also require placing a simple adjunct. I don't see those things mentioned at all when people talk about apneic oxygenation. Most patients can be ventilated with positive pressure, but if you do that you've pretty much obviated the use of a NC.

If you can visualize the glottis, then of course there is a clear route for the oxygen. But at that point they are intubated anyway.

I know there are some patients who don't have any obstruction and are still hard to mask or intubate for other reasons, and they are probably the ones who can benefit from this. But for the most part, the conditions that cause difficult intubation and mask ventilation are the same ones that case airway obstruction.

 

[Tigger]

That was my first thought. But in the video that was posted, he stressed how you should use two people anyway so that you can maintain visualization until the cuff is past the cords.

When I learned it, the technique was taught as a way to help someone in a single provider role. The instructor stressed sinking the bougie and holding it there. So long as you don't pull back on the bougie while advancing the tube, it would be difficult for the tube to not enter the trachea.

That said, I find that getting the tube to pass under the epiglottis can be difficult at times, so it would nice to watch that so I could adjust accordingly.

 

[CANMAN]

I have a bougie out, and at the ready for every intubation, but I don't use it for every single tube. Everyone is going to have their own method that they're comfortable with, but for me, most of the time, it's a device that isn't needed and is an unnecessary step.

In the video the intubation attempt is done with a CMAC, and he gets a grade 1 view right off the bat with proper technique. There is a point where he has slight difficulty passing the tube off the bougie, and in my opinion with that initial view a regular ETT and stylette would pass without any hang up. This has been my expierence and the tube requires that rotation 90% of the time. In my opinion it makes an easy airway/tube more difficult and thus why I don't use it for every tube. Just my opinion though, if it works for you keep on with it!

 

[Bullets]

This is how we were taught in medic class, didnt know it had a name. I guess since thats how i learned it thats what im most comfortable with. I use a bougie on every tube, we would have to load the stylus anyway, so i just load the bougie instead.