Bougie Use in the Field
Objective: Use an intubating introducer (bougie) the way you were trained. Feel for tracheal clicks, then slide the tube over the bougie. If the bougie keeps sliding and you have lost the view, stop and give oxygen.
Why this matters
Sometimes you can see the epiglottis and still cannot see the opening. Crews push the tube and hope. The cuff then inflates in the esophagus.
A bougie is an intubating introducer. Use it as a planned change of tool if you are trained and it is in your hand. It is not a rule that every first pass must use a bougie. A bougie is a new plan. It is not a way to repeat the same look.
- Hold the bougie before the look. Do not leave it in the outside pocket of the airway bag.
- Slide the tube over the bougie without letting the bougie move. A partner holds it.
- Confirm with a waveform. Clicks are a clue. They do not replace end-tidal carbon dioxide (EtCO₂), the carbon dioxide waveform on the monitor.
Clinical sequence
- Have the bougie in your hand before you look.
- Get the best view you can. Pass the bent tip, called a coudé tip, under the epiglottis and toward the opening of the larynx.
- Feel for clicks from the tracheal rings. Feel for the bougie stopping at the carina. That stop is called hold-up. If it is quiet and the bougie keeps sliding, you may be in the esophagus. Come out, give oxygen, and change the plan.
- Slide the tube over the bougie. Some crews call that railroading the tube. Do not let the bougie slip deeper, and do not pull it out, while the tube goes in. A partner holds the bougie. If the tube catches on the arytenoids, rotate the tube and try again.
- Confirm with chest rise and a waveform. Clicks do not replace EtCO₂.
- If the tube still will not pass after you have changed the plan, a supraglottic airway is still an option. The bougie is not a reason for a fourth identical look.
Teaching points
- Clicks and a stop at the carina mean you are likely in the trachea. The esophagus is quiet, and the bougie keeps going. Come out if that is what you feel.
- Leave the bougie in place, slide the tube over it, then remove the bougie. Rotate the tube if it catches on the arytenoids.
- A bougie after a failed tube pass is a new plan. The same look with the same blade is not a new plan.
- A supraglottic airway is an acceptable advanced airway in adult cardiac arrest when you cannot place the tube.
Common errors
- Pushing until you make a false passage. That is a path you created that is not the airway.
- Calling clicks a success without seeing the cords or confirming EtCO₂.
- Leaving the bougie in the bag because this one will be easy.
Practice
One-minute check
Partner: you can see the back of the glottis, the bougie clicks, and the tube will not pass. What do you change next? Then there are no clicks, and the bougie keeps going. Where is it, and what do you do? Then it is cardiac arrest after two failed looks. Name the next tool.
Related: Difficult Airway, Front-of-neck access.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; follow your protocol
- Difficult Airway Society guidelines hub — introducer as a change of technique, not endless attempts
- AHA 2025 Part 9: Adult ALS — limit hypoxia around the time you put the tube in; an SGA is acceptable
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.