Upper airway injury caused by gum elastic bougie

Abstract

International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations. IJCRI publishes ABSTRACTIntroduction: Difficulties and complications associated with intubation are among the leading causes of surgery-related mortality in patients with obesity and obstructive sleep apnea. It is known that during perioperative intubations, the progression of the bougie may lead to serious injury and even rupturing in the trachea. Case Report: A 46-year-old ASA II patient was assessed preoperatively for uvuloplasty. His body mass index was 34.7. Preparation was completed for the difficult intubation. The patient could not directly intubated with laryngoscopy but was intubated with bougie in the second trial. After the surgery 200 mg bridion was administered and the patient was extubated. He was then followed-up in PACU. Due to the stridor, it was thought that there was edema in his upper airway. At 45 minutes of PACU follow-up, it was noticed that upper airway edema regressed but there was subcutaneous emphysema giving a sense of rattle during palpation in the periphery of the right eye. It spread rapidly over the face. Afterwards he was intubated again through video laryngoscopy due to the risk of upper airway obstruction. Fiber optic examination and thorax tomography revealed that the fistula line was on the left lateral wall following cricoid cartilage. Mucosal damage of the patient healed spontaneously and weaning was conducted three days later in the ICU. Conclusion: It was reported that tracheal injury and rupture occurs due to 'blind' advancement of the bougie during intubation. Due to the identification of subcutaneous emphysema at 45 minutes during follow-up, it was thought that the bougie caused injury in the patient. The close long-term postoperative follow-up is important in cases where difficult intubation is conducted with bougie and intubation is achieved through multiple trials.

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation

“… The coudé tip of the bougie can occasionally impinge on the anterior larynx after passing through the glottis; this is remedied by slight withdrawal of the bougie, rotation of the tip posteriorly, and advancement . Few instances of bougie-related complications have been reported in the literature, and the bougie is generally viewed as a safe device; this trial supports this view, with complications being rare in both groups without clear causative links. Use of the hold-up sign, however, may increase the risk of pneumothorax, especially if the bougie does not have a coudé tip, which allows penetration of the bougie into smaller, more fragile bronchi .…”

Delayed Pneumothorax Following Bougie-Assisted Nasal Intubation

“…In general, 0.5 to 7% of adverse events associated with difficult intubation are due to trauma [ 10 ]. Those from bougie use are even less and typically involve single-use bougies as they are less flexible and the coating makes sliding the ETT over it more difficult [ 5 , 11 ]. The use of a lubricant on the bougie can assist with the latter issue.…”

“…The use of a lubricant on the bougie can assist with the latter issue. Because of the tip design (angled instead of straight), there is supposed to be less risk of injury as it is supposed to limit the depth of insertion [ 11 ]. Recommended bougie insertion depth has varied from 25cm to 35cm according to some reports, while others used resistance as their guide [ 12 ].…”

“…Recommended bougie insertion depth has varied from 25cm to 35cm according to some reports, while others used resistance as their guide [ 12 ]. Nevertheless, too much pressure, not stabilizing the bougie, or not withdrawing it a couple of cm prior to ETT placement can lead to injury [ 11 ]. Maintaining direct visualization (via direct laryngoscopy or Glidescope) during placement of the ETT over the bougie can also help prevent injury [ 9 ].…”

Large airway complications in COVID-19 pneumonia

“…Laryngeal tears affecting the membranous trachea are well described in association with endotracheal intubation [13] and although considered safe there are case reports in the non-Covid literature describing laryngeal damage with bougie use [14,15].…”