Airway injury caused by a Portex single-use bougie.

To the Editor: The tracheal tube introducer (bougie) is widely used to facilitate difficult intubation. However, single-use introducers, compared to reusable ones, appear to be more traumatic [1-3]. A 61-year-old woman with esophageal reflux and no predictive signs of difficult intubation received rapidsequence induction with application of cricoid pressure. Direct laryngoscopy revealed a Cormack-Lehane grade 3 view. An unlubricated Single Use Tracheal Tube Introducer (SIMS Portex, Hythe, Kent, UK) was advanced into the trachea without any resistance. Correct placement was indicated by the tracheal “clicks” sensation. The tracheal tube was advanced easily over the bougie and through the larynx, without 90° anticlockwise rotation. However, when attempting to remove the bougie, it was stuck inside the tracheal tube. We succeeded in removing it by withdrawing it gradually, as gently as possible. After the endotracheal tube was connected to the breathing system, we noticed blood coming out of the tube. Mild endotracheal suction was performed repeatedly and bleeding gradually ceased. Hypoxia did not occur at any time. When the surgery was completed, the patient recovered uneventfully and her postoperative course was uncomplicated. The Portex single-use bougie was introduced in 1997, due to concerns about microbial contamination via multiple use. It has a different design from the multiple-use introducer [4]. The Portex Venn Reusable Tracheal Tube Introducers are made with a braided polyester base with a resin coating, while the single-use Portex introducer is a hollow tube, coated with plastic. The difference in material may explain the increased resistance we felt between the introducer and tube, and the difficulty in withdrawing the unlubricated bougie from the tube. Zwaal and Gupta also described an inability to advance a tracheal tube over an unlubricated single-use Portex bougie [5]. The manufacturer recommends that tracheal introducers be lubricated before use. The airway trauma may not have been related to the difficulty in removing the introducer, as it may have occurred when the bougie was advanced into the trachea. Another possible mechanism is tissue blockage between the angled distal end of the introducer and the tracheal tube when the bougie was withdrawn. The multiple-use introducer has an angled (40°) tip with rounded end, while the single-use bougie has an angled, less flexible tip with a more flattened end. The peak force exerted by the single-use bougie on tissue is greater, especially when it is held close to the tip [1-3]. These characteristics render the single-use bougie more likely to cause tissue injury than the multiple-use device [6]. In light of our experience, the anesthesiologists in our department agreed not to use single-use introducers in their practice any longer. It should be stressed that the 1997 version of the Portex single-use introducer is no longer produced. Although many departments still use the “old” version, a new version is available. The quality of single-use equipment should be improved, in order to be safe and effective when used.