the bougie is typically held by the intubator 20- 30 cm proximal to the coude tip
the bougie should be inserted via the side of the mouth, rather then down the center, so that rotation of the bougie provides better control of the coude tip in the vertical plane
it is typically inserted directly into the trachea and then used as a guide over which the endotracheal tube can be railroaded (analogous to the Seldinger technique)
it can be preloaded with an endotracheal tube or an assistant can pass the endotracheal tube over the free end of bougie while the intubator maintains visualisation of the bougie/ cords and ensures the placement of the bougie remains secure
the assistant should continuously walk their hands down the bougie as the endotracheal tube is advanced over it
the tracheal tube should be introduced through the cords, over the bougie, using a 90º anti-clockwise rotation to prevent its beveled point from getting caught in the arytenoids
the user should feel the tip of the bougie ‘click’ as it passes along the tracheal rings
when used to confirm endotracheal placement the bougie is passed down the endotracheal tube and there should be ‘hold up’ at 30-40cm depth, if this does not occur the bougie is likely to be in the esophagus.
the bougie may be passed into one of the main bronchi by twisting the angled tip in the preferred direction, this may be useful to facilitate endobronchial intubation (e.g. in massive hemoptysis where other equipment is unavailable)
the ‘Kiwi grip’ can be used by a solo operator – the bougie is curled upon itself and preloaded with an endotracheal tube (see here and here), as can the ‘pistol grip’ (when the bougie is held together with the laryngoscope in one hand – see here).