The Protected Airway CollaborativeLearn · Practice · PerformCollection 05/07Evolution of the Tube Introducer · 05/07
One OperatorOne Assembly
Move the loading step before laryngoscopy. Keep the bougie and tube together. Preserve enough working length to reach the trachea.
- Technique
- Preloaded · D-grip
- Critical requirement
- 70 cm introducer
- Setting
- Hands-on station
Change the order · preserve the objective
Load before the view.Protect the working length.
In the classic sequence, the tube is loaded after the bougie enters the trachea. The preloaded technique moves that task before laryngoscopy, allowing one operator to hold the tube and bougie as a single assembly.
The efficiency comes with a geometric requirement: the tube occupies part of the introducer before the procedure begins. A 70 cm bougie preserves enough free distal length to reach the trachea while leaving enough proximal length to control the assembly and deliver the tube.
Preserve working length
Use a 70 cm introducer and position the tube so enough bougie remains free to reach and enter the trachea.
Build the D-grip
Hold the preloaded tube and bougie as one controllable assembly while keeping the distal tip free to move.
Remove slack, then deliver
After bougie placement, remove slack without changing distal depth, then railroad the tube over the stable guide.
Preload deliberately. Then place and deliver.
Preloading removes the mid-procedure tube-loading step, but it makes preparation unforgiving. Confirm the introducer length, build a controllable D-grip, and know exactly how much bougie remains available before laryngoscopy begins.
- 01
Verify 70 cm
Confirm the introducer is 70 cm long and compatible with the selected tube. A shorter device may leave too little working length once the tube is preloaded.
- 02
Load and form the D-grip
Position the tube on the bougie, form the D-shaped assembly, and keep the distal tip freely controllable in the intubating hand.
- 03
See, place, and stop
Obtain the glottic view, direct the bougie into the trachea under vision, and stop at a deliberate depth.
- 04
Remove slack, then railroad
Hold distal bougie depth constant while removing slack from the assembly. Once the guide is stable and the path is direct, advance the tube.
Field observation
Most failures are built into the setup.
Preparation errors leave too little working length, excess slack, or a poorly controlled tip. Execution errors lose bougie depth during the pull-tight transition or force the tube when it hangs up.
- Preparation: wrong introducer length, poor tube position, uncontrolled D-grip.
- Execution: lost distal depth, incomplete slack removal, forceful tube advancement.
01Troubleshoot lost length+
If the bougie cannot reach the target or too little shaft remains for controlled tube delivery, stop and examine the assembly. The usual causes are an introducer that is too short, a tube loaded too distally, or slack that was never removed.
Do not compensate by advancing blindly or surrendering control. Rebuild the assembly with the correct device and working length.
Leave the screen
Build the margin before the airway.
At the station, build and rebuild the preloaded system until the 70 cm length check, D-grip, and pull-tight transition are reproducible. Make the remaining working length visible before every attempt.
Open preloaded bougie guided practice ↗- 01
Compare a 70 cm introducer with a shorter device after the same tube is loaded.
- 02
Build the same D-grip reliably while preserving free distal tip control.
- 03
Rehearse lost-length, residual-slack, and tube-impingement corrections.
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