NextGen Learning To Elevate Your Airway Practice
Bougie First
Seldinger Technique for the Airway
Instead of directly inserting the endotracheal tube (ETT) into the trachea under direct or video laryngoscopy, this technique starts with the bougie’s insertion into the trachea, which is the most common way that a bougie is used.
Step-by-Step Guide to the Standard Bougie-Assisted Intubation
1. Preparation & Positioning
- Ensure the patient is properly positioned in the sniffing position (or ramped for obese patients).
- Pre-oxygenate the patient using a bag-valve mask or non-rebreather.
- Confirm your equipment is ready, including:
- Bougie (preferably a 70cm, coude-tipped model)
- Endotracheal tube (ETT) sized appropriately for the patient
- Laryngoscope (direct or video)
- The suction device is on and ready
- Bag-valve mask connected to oxygen
2. Laryngoscopy & Bougie Placement
- Using your laryngoscope, perform laryngoscopy to visualize the glottis.
- If the view is Grade I or IIa, proceed.
- If visualization is more difficult (Grade IIb-III), optimize your view with maneuvers like external laryngeal manipulation or repositioning.
- Once the glottis is identified, insert the bougie first, gently advancing it through the vocal cords.
- If using a coude-tipped bougie, the angled tip should be directed anteriorly to navigate the airway.
- Advance until you are safely within the trachea. You may feel the characteristic tracheal ‘clicks’ or hold-up at the carina (~35-40 cm), but neither of these are confirmatory.
3. Advancing the Endotracheal Tube
- Keeping the bougie stable, carefully slide the lubricated ETT over the bougie (“railroading” the tube).
- If resistance is met at the glottic opening, consider:
- Slight counterclockwise rotation of the ETT
- Adjusting head and neck position
- Retracting slightly and reattempting
4. Tube Placement & Confirmation
- Once the tube has passed the vocal cords, hold the ETT firmly while a second operator removes the bougie.
- Inflate the cuff, attach capnography, and confirm placement using:
- End-tidal CO₂ waveform (gold standard)
- Bilateral chest rise
- Auscultation for breath sounds
- Absence of gastric insufflation
- Secure the ETT and continue mechanical ventilation or bag ventilation as necessary.
🔑Key Tips for Success:
✅ Use a gentle, controlled technique when inserting the bougie to avoid airway trauma.
✅ Expect slight resistance at the glottis—if there is tube hangup on delivery, pull the tube back slightly and use rotational maneuvers.
✅ Using an Assistant–helps streamline the technique and allows you to focus on the airway.
Rapid Review
Is real-time too slow for you? This high-speed selection will jog your memory, give you the highlights, and prime R for what comes next. ⏩
The Technique
Dig into the details and watch this full procedure video on the classic bougie technique. You can do it solo if you don’t have a partner, but it works great with two!
Can I Get an Assist
The choreography of bougie-assisted intubation requires that you be in sync with the intubator. Watch this to ensure you know your role’s basic responsibilities and timing.
Microskills
The little details matter
Watch any expert closely, and you will see that the little details matter, those subtle gestures that separate the amateur from the pro. Review this collection of microskills & gestures for the assisted bougie so that you can perform this procedure flawlessly. Even better, grab a bougie, tube & syringe and follow along to encode those tactile skills into your long-term memory at home or one of our coaching stations 🧠
Troubleshooting
What’s YOUR HANG-UP?
In bougie speak, “hang-up” often refers to issues that occur with tube delivery, but before that, the bougie itself can often get “hung-up” on anatomic structures as it travels from the hypopharynx to the distal trachea. Here’s a quick guide on the most common spots where this can occur and what to do about it based on the location.
supercharge your rotation
Rotating the bougie can help you get that coude tip off the tracheal rings, but what is the best technique?
Don’t Forget to Practice!
This poster has associated hands-on learning opportunities in our immersive and interactive physical space. If you’re with us in person, please visit the related station and use the self-guided resources here.
Curated MedEd
Dive Deeper
We curate some of the best online resources so you can dive deeper into this topic and build your learning network. Follow some of these great educators for great learning. We do!!
This video was created 12 years ago and remains a classic. No bougie learning would be complete without it. We recommend watching all of John’s videos.
What’s Next
Find Or Click Me
Nice work—you’re through this section! To keep going, scan the QR code on the physical poster at the next station in our pop-up training space to access the next set of digital content. Prefer to stay online? Just click the poster image here to continue your journey.
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