Bougie-assisted Tracheostomy: A Useful Modification in Low Resource Settings

The use of a bougie is crucial during the placement of a tracheostomy tube (TT) in patients on mechanical ventilation. One of the practices for placing a TT involves utilising a fibreoptic scope (FOB) through endotracheal tube (ETT)[1] along with end-tidal carbon dioxide (ETCO2) attached to TT. However, there are situations in which the ETT might accidentally get displaced during the procedure and simultaneously if the TT enters a false passage,[2] leading to serious complications. The FOB significantly reduces this risk by facilitating the railroad of the ETT. In many low-resource environments, access to a FOB and sometimes, ETCO2 monitoring can be limited. In such cases, a practical alternative is to insert the bougie into the ETT, extending it beyond the tip of the ETT. This technique gives the surgeon better visibility and tactile feedback during TT insertion. The bougie’s small diameter helps in accommodating the TT within the trachea more easily. If the tracheal tube navigates into the false passage, the ETT can be easily railroaded over the bougie, thus securing the airway and minimising potential harm. If available, an airway exchange catheter is preferable. Our institution has successfully employed this method on numerous occasions. The ETT connects proximally to a catheter mount [Figure 1], allowing either an FOB or a bougie to be used while the patient continues to receive ventilation. Once the surgeon identifies the trachea, the bougie is inserted with the curved tip out until it extends beyond the tip of the ETT. The surgeon then makes a small nick in the trachea to locate both the bougie and the ETT. At this point, the ETT is carefully withdrawn while keeping the bougie in place. After confirming TT placement through sustained ETCO2 tracing, both the bougie and the ETT are removed.Figure 1: Assembly of catheter mount, bougie and endotracheal tubeThe limitation of this technique is the risk of suboptimal ventilatory parameters for a very brief period. If this situation arises, we can swap out the adult bougie for a paediatric one. In addition, if we encounter any challenges while inserting the bougie through the catheter mount, applying some lubricant can help ease the process. Furthermore, anaesthesia may be delivered with an additional dose of propofol bolus as inhalational anaesthetic is generally shut off. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.