posted on the Anaesthesia corres-

pondence website: www.anaesthesia

correspondence.com.

References1. Paul A, Gibson AA, Robinson ODG, Koch

J. The traffic light bougie: a study of anovel safety modification. Anaesthesia2014; 69: 214–8.

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: 379–84.

4. Rai MR. The humble bougie. . .fortyyears and still counting? Anaesthesia2014; 69: 199–203.

5. Marson BA, Anderson E, Wilkes AR, Ho-dzovic I. Bougie-related airway trauma:dangers of the hold-up sign. Anaesthe-sia 2014; 69: 219–23.

6. Stone DJ, Bogdonoff DL. Airway consid-erations in the management of patientsrequiring long-term endotracheal intu-bation. Anesthesia and Analgesia 1992;74: 276–87.

7. El-Orbany MI, Salem MR, Joseph NJ. TheEschmann tracheal tube introducer isnot gum, elastic, or a bougie. Anesthesi-ology 2004; 101: 1240.

doi:10.1111/anae.12699

Bougies – or capnography?

We read with interest the concerns

raised about the bougie hold-up

sign causing airway trauma [1]. The

use of this sign in determining the

position of the bougie is superior to

tracheal ‘clicks’ alone, as shown by

Kidd and colleagues [2]. In the arti-

cle by Paul and colleagues [3], 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 [4], may offer such

confirmation.

F. A. MillarG. L. HutchisonNinewells HospitalDundee, UKEmail: fergus.millar@nhs.net

No external funding or competing

interests declared. Previously posted

on the Anaesthesia correspondence

website: www.anaesthesiacorrespon

dence.com.

References1. Marson BA, Anderson E, Wilkes AR, Ho-

dzovic I. Bougie-related airway trauma:dangers of the hold-up sign. Anaesthe-sia 2014; 69: 219–23.

2. Kidd JF, Dyson A, Latto IP. Successful dif-ficult intubation. Use of the gum elasticbougie. Anaesthesia 1988; 43: 437–8.

3. Paul A, Gibson AA, Robinson ODG, KochJ. The traffic light bougie: a study of anovel safety modification. Anaesthesia2014; 69: 214–8.

4. Millar FA, Hutchison GL, Glavin R. Gumelastic bougie, capnography and ap-noeic oxygenation. European Journal ofAnaesthesiology 2001; 18: 51–3.

doi:10.1111/anae.12701

Preloading bougies

We read with interest the report of

airway trauma related to the use of

gum-elastic bougies during airway

management [1]. The accompany-

ing editorial succinctly summarises

the past, present and possible future

of the ‘humble’ bougie [2].

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’ [3].

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, 511–526