posted on the Anaesthesia corres-
pondence website: www.anaesthesia
References1. Paul A, Gibson AA, Robinson ODG, Koch
J. The traffic light bougie: a study of anovel safety modification. Anaesthesia2014; 69: 2148.
2. Cook T, Woodall N, Frerk C. Major com-plications of airway management inthe United Kingdom. 4th National AuditProject of the Royal College of Anaes-thetists and the Difficult Airway Society:Report and findings. London: RCoA,March 2011.
3. Latto IP, Stacey M, Mecklenburgh J,Vaughan RS. Survey of the use of thegum elastic bougie in clinical practice.Anaesthesia 2002; 57: 37984.
4. Rai MR. The humble bougie. . .fortyyears and still counting? Anaesthesia2014; 69: 199203.
5. Marson BA, Anderson E, Wilkes AR, Ho-dzovic I. Bougie-related airway trauma:dangers of the hold-up sign. Anaesthe-sia 2014; 69: 21923.
6. Stone DJ, Bogdonoff DL. Airway consid-erations in the management of patientsrequiring long-term endotracheal intu-bation. Anesthesia and Analgesia 1992;74: 27687.
7. El-Orbany MI, Salem MR, Joseph NJ. TheEschmann tracheal tube introducer isnot gum, elastic, or a bougie. Anesthesi-ology 2004; 101: 1240.
Bougies or capnography?
We read with interest the concerns
raised about the bougie hold-up
sign causing airway trauma . The
use of this sign in determining the
position of the bougie is superior to
tracheal clicks alone, as shown by
Kidd and colleagues . In the arti-
cle by Paul and colleagues , the
novel use of a traffic light depth
gauge actively discourages the use
of hold-up as an endpoint, relying
solely on clicks. If we are to avoid
the hold-up sign, then the accuracy
of bougie positioning may be
reduced, and perhaps it is time to
look for another way of confirm-
ing bougie position. The use of cap-
nography, as described by Millar
and colleagues , may offer such
F. A. MillarG. L. HutchisonNinewells HospitalDundee, UKEmail: firstname.lastname@example.org
No external funding or competing
interests declared. Previously posted
on the Anaesthesia correspondence
References1. Marson BA, Anderson E, Wilkes AR, Ho-
dzovic I. Bougie-related airway trauma:dangers of the hold-up sign. Anaesthe-sia 2014; 69: 21923.
2. Kidd JF, Dyson A, Latto IP. Successful dif-ficult intubation. Use of the gum elasticbougie. Anaesthesia 1988; 43: 4378.
3. Paul A, Gibson AA, Robinson ODG, KochJ. The traffic light bougie: a study of anovel safety modification. Anaesthesia2014; 69: 2148.
4. Millar FA, Hutchison GL, Glavin R. Gumelastic bougie, capnography and ap-noeic oxygenation. European Journal ofAnaesthesiology 2001; 18: 513.
We read with interest the report of
airway trauma related to the use of
gum-elastic bougies during airway
management . The accompany-
ing editorial succinctly summarises
the past, present and possible future
of the humble bougie .
In our bariatric anaesthesia
practice, we have found wide use
for the bougie and often use it elec-
tively in super-morbidly obese
patients. The bougie is very useful
when there is an occlusive prolifera-
tion of oropharyngeal soft tissues,
as seen in obstructive sleep apnoea
and obesity, keeping the time to
tracheal intubation as short as
possible and avoiding having to
implement a rescue Plan B .
We have developed a simple
innovation for use of the bougie in
bariatric anaesthesia (that may be
applicable to other situations), the
Preloaded Bougie Technique, in
which the bougie is electively pre-
loaded into the tracheal tube and
held in place by the pilot balloon
(Fig. 1). After induction of anaes-
thesia and under direct laryngos-
copy, the anaesthetist holds the
bougie and inserts its curved distal
Figure 1 Preloaded bougie.
2014 The Association of Anaesthetists of Great Britain and Ireland 515
Correspondence Anaesthesia 2014, 69, 511526