Utilization of a gum elastic bougie to facilitate single lung intubation

Patients with severe pulmonary hemorrhage due to unilateral trauma or a bleeding cancer often present to the emergency department in acute respiratory distress. Although it is generally recommended to perform single lung intubation, most emergency department providers do not have access to or are not familiar with double-lumen endotracheal tubes, and blind insertion of an endotracheal tube to maximum depth does not ensure that the proper (nonhemorrhagic) lung is ventilated. Therefore, single lung intubation may be significantly delayed in these patients. The purpose of this study was to assess the accuracy of using a gum elastic bougie ("bougie") to facilitate single lung intubation.

We conducted a prospective, randomized, blinded pilot study assessing the accuracy of bougie-guided single lung intubation in a fresh human cadaveric model. Two investigators each inserted a bougie under video laryngoscope guidance. After passing the vocal cords, the intubator would be randomized to turn the bougie 90° clockwise (for right mainstem intubation) or 90° counterclockwise (for left mainstem intubation). The bougie was then advanced until resistance was met, and the endotracheal tube was subsequently advanced over the bougie. After intubation, a board-certified pulmonologist investigator who was blinded to the initial lung selection used a fiberoptic bronchoscope to confirm placement by assessing endotracheal tube location with respect to the carina. The primary outcome was the accuracy of correct lung placement.

Two providers performed a total of 45 placements. There were 22 right mainstem and 23 left mainstem intubations. The overall accuracy was 100% (95% confidence interval, 90.2%-100%) for both right and left mainstem intubations.

In our cadaveric model of mainstem intubation, bougie-guided single lung intubation was highly accurate for both left and right mainstem intubations. Future studies should assess the accuracy of this technique among different providers and bodies, as well as live patients.