The Protected Airway CollaborativeLearn · Practice · PerformCollection 04/07Evolution of the Tube Introducer · 04/07
Bougie FirstBuild the Route
See the glottis. Place the bougie. Railroad the tube. One operator can complete the sequence—but a well-choreographed assistant makes it better.
- Technique
- Classic bougie-first
- Sequence
- View · place · railroad
- Preferred workflow
- Two-person choreography
One technique · two ways to execute it
Solo is possible.Assisted is better.
The classic technique begins with the intubator obtaining a useful view of the glottis, placing the bougie into the trachea, and railroading the endotracheal tube over that guide. A single operator can perform the entire sequence.
An assistant is not required, but a well-trained assistant reduces the number of hand transitions the intubator must manage while maintaining laryngoscopy and bougie depth. The advantage appears only when the roles, language, and handoffs are deliberately choreographed.
Establish the route
Obtain the best useful glottic view and direct the bougie through the laryngeal inlet into the trachea.
Protect the position
Maintain the view and bougie depth while the tube is loaded—whether working alone or with an assistant.
Railroad the tube
Advance the tube over the stable guide, respond deliberately to resistance, and complete the sequence without losing access.
Watch · handle · rehearse
Learn the complete sequence before dividing the work.
The clinical sequence does not change: obtain the view, place the bougie, preserve tracheal access, and railroad the tube. Practice it first as one continuous procedure. Then decide which transitions an assistant can make easier.
Obtain the view
Prepare compatible equipment, position the patient, and create the best useful view of the glottic opening.
Place the bougie
Direct the tip through the laryngeal inlet into the trachea while maintaining control of the laryngoscope and introducer.
Protect the route
Hold the bougie at a stable depth while the tube is loaded. Working solo requires the intubator to manage this transition; an assistant can perform it instead.
Railroad and confirm
Advance the tube over the guide, correct resistance without force, remove the bougie, inflate the cuff, and confirm tracheal placement.
An assistant improves the sequence—if the choreography is clear.
The complete procedure can be performed solo. With an assistant, the intubator can maintain the view and bougie position while the assistant loads the tube and supports the remaining transitions. Practice that division of labor explicitly.
01Troubleshooting resistance+
Tube passage can fail even when the introducer is correctly positioned. Use this demonstration to study impingement, controlled withdrawal, and corrective rotation rather than forcing the tube.
02Expert demonstration+
Compare the PAC choreography with an additional full technique demonstration. Look for differences in role assignment, handoff language, introducer control, and tube delivery.
Leave the screen
Rehearse it solo. Then rehearse it as a team.
First perform the entire view–bougie–tube sequence alone so every transition is understood. Then add an assistant and deliberately transfer the tasks that reduce the intubator’s hand burden without surrendering control of the airway.
Press play, leave the screen, and follow the guided sequence at the handling station.
- 01
Solo: maintain laryngoscopy and bougie depth while loading and advancing the tube.
- 02
Assisted: use explicit calls—“bougie secure,” “load the tube,” and “tube secure, remove the bougie.”
- 03
Compare both workflows, then rehearse impingement correction without forcing the tube or surrendering the route.
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