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Bougies, Stylets, and Aintree
TEXTAirway II · 8 min read
When direct view is partial or absent, these guides bridge the gap from cords to trachea.
After this lesson you can
4 min read8 sections- Choose the right airway adjunct for the scenario.
- Use the gum elastic bougie correctly.
- Apply Aintree exchange catheter when needed.
- Recognize when stylets cause harm.
Gum elastic bougie — what it is, when to reach for it
Standard length 60 cm, diameter 15 Fr (adult).
The 30-40° angled tip is what allows it to find the anterior airway when the cords are not in view.
DAS 2015 recommends bougie as the FIRST rescue, BEFORE attempt 2 of laryngoscopy in any difficult view.
It is the highest-yield, lowest-cost difficult-airway tool on the cart.
Bougie technique step-by-step
Common bougie problems and fixes
- withdraw 1-2 cm
- rotate
- advance again
If still stuck: downsize the ETT (7.5 → 7.0).
Bougie won't pass anteriorly: lift the laryngoscope blade more aggressively (you may not have a good view), reposition head, try a Miller blade for direct epiglottis lift, or pre-shape the coude tip to a more acute angle.
Persistent failure after 3 bougie attempts escalate to video laryngoscope, SGA, or fiberoptic.
Standard malleable stylet
Bend the tube + stylet to the anticipated airway curve before intubation — most commonly a 'hockey stick' shape for direct laryngoscopy.
The stylet tip should NOT extend past the ETT tip — this risks tracheal posterior wall perforation.
Once the tube passes the cords, partially withdraw the stylet so the soft ETT tip advances atraumatically into the trachea.
Leaving a rigid stylet in past the cords during further advancement is a documented mechanism of tracheal injury and posterior membrane perforation.
Hyperangulated rigid stylet (Glidescope-style)
Pre-formed in a ~70-90° curve matching the blade geometry.
ETT is loaded over the stylet and the entire assembly is delivered as one unit.
Reaches the anterior airway that a flexible stylet would not navigate.
Technique: align tube + stylet tip with cords on screen advance into trachea withdraw stylet 2-3 cm before advancing tube fully (otherwise the rigid tip catches on the tracheal wall).
Two-person delivery often easier — assistant pulls stylet while operator advances tube.
Aintree intubation catheter — SGA-to-ETT exchange
The Aintree's lumen allows jet ventilation or oxygen insufflation if oxygenation is needed during the exchange.
Other airway exchange catheters
Passed through the ETT before extubation, ETT removed, AEC remains in trachea — patient can speak and cough around it.
If reintubation needed: oxygenate via AEC (15 L/min) + railroad ETT over AEC.
Sizes 11 Fr, 14 Fr, 19 Fr (adult).
Hazards: bronchial perforation from advancing too far, barotrauma from high-pressure jet ventilation.
Limit insertion depth to 25 cm.
Tube exchanger differs from intubating bougie — purpose-built for reintubation, not first-intubation guide.
Putting it together — algorithm for partial view
Cormack IIb-III: reach for the bougie (DAS 2015 explicit recommendation).
Cormack IV with rescue oxygenation available: video laryngoscope (hyperangulated + rigid stylet) or SGA-fiberoptic-Aintree.
Cormack IV + cannot oxygenate: surgical airway (FONA).
The bougie is the single highest-yield tool when the view is partial — practiced reach-for is the muscle memory that saves attempts.
Have it within hand-reach for every intubation, not buried in a drawer.
⚠ Common pitfalls
- Bougie blindly without the tracheal-click landmark — esophageal placement possible.
- Stylet too stiff or too far past the tube tip — soft-tissue trauma.
- Aintree without preserving oxygenation — it's an exchange, not a rescue device alone.
- Pulling the stylet too early during intubation — tube angle collapses, fails delivery.
💎 Clinical pearls
- Tracheal click + hold-up at 25-40 cm = correctly placed bougie.
- Eschmann bougie (gum elastic) is the cheapest, most-effective airway adjunct ever invented.
- Aintree-assisted FOB: exchange catheter through SGA → FOB through catheter → tube over → bridge to definitive airway.
- Hyperangulated stylet must match the VL blade curve — Glidescope-specific stylets exist for a reason.
Recap
- Tracheal click + hold-up at 25-40 cm = correctly placed bougie.
- Eschmann bougie (gum elastic) is the cheapest, most-effective airway adjunct ever invented.
- Aintree-assisted FOB: exchange catheter through SGA → FOB through catheter → tube over → bridge to definitive airway.
- Hyperangulated stylet must match the VL blade curve — Glidescope-specific stylets exist for a reason.
Mark each section done to complete the module.