Successful difficult intubation. Tracheal tube placement over a gum-elastic bougie

A randomised study was carried out to assess the effect of tracheal tube rotation on the passage of a tube over a gum-elastic bougie into the trachea in 100 patients. The effect of the presence or absence of a laryngoscope on successful tube placement was also assessed. A grade 3 difficult intubation was simulated in patients with a laryngoscope. There was a significant difference in the rates for successful first-time intubation in those patients with tube orientation of -90 degrees (with the bevel facing posteriorly) as compared with a tube orientation of 0 degrees (the normal orientation with the bevel facing left). The unsuccessful first-time intubations with a 0 degree orientation were frequently converted to successful intubations with the -90 degrees position at a second attempt. The presence of a laryngoscope in the mouth while rail-roading a tube over the bougie also made a significant difference to the rate of successful first-time intubations. The most successful method was to leave the laryngoscope in the mouth and rotate the tube to -90 degrees.