When to Use Bougies? Understanding Medical Applications in Intubation and Dilation

September 23, 2025 •

3 min read

Studies have shown that using a bougie can significantly increase the success rate of first-attempt intubation in emergency departments, especially in difficult airway scenarios. Knowing when to use bougies, whether for airway management or for therapeutic dilation, is a vital skill for medical professionals that improves patient outcomes.

Quick Summary

A bougie is used by medical professionals to assist with difficult tracheal intubation when the airway is not easily visualized, and also to safely dilate strictures or narrowings in the esophagus, urethra, or other body lumens. Proper application depends on the specific clinical context and patient's condition.

Key Points

Difficult Intubation: A bougie, or endotracheal introducer, is used to assist in placing an endotracheal tube in patients with a poor or limited view of the larynx.
Esophageal Dilation: Bougies are used to stretch and widen strictures or narrowed areas in the esophagus, often caused by acid reflux or other conditions.
Tactile Confirmation: During intubation, a bougie's design allows the user to feel tactile feedback (clicking over tracheal rings) to confirm correct placement.
Multiple Sizes: For dilation, a series of bougies of increasing sizes are used to gradually widen the narrowed passage.
Patient Assessment: A thorough evaluation of the patient's anatomy and condition is necessary before using a bougie to prevent complications such as perforation.
Proper Technique is Vital: The procedure requires skilled technique and training to ensure patient safety and avoid potential complications like esophageal tearing or tracheal damage.

What is a Bougie?

Originally named for their candle-like shape, bougies are slender, flexible or semi-rigid medical instruments used to facilitate a variety of procedures. Their application has evolved significantly over time, and the term can refer to different devices depending on the medical context. The two primary uses are as an endotracheal introducer for airway management and as a dilator for treating strictures in hollow organs. Understanding the specific type of bougie and its intended function is crucial for safe and effective use.

The Bougie for Airway Management

The gum elastic bougie (GEB), often called an Eschmann introducer, is a widely used tool to aid in endotracheal intubation, particularly when the physician has a poor or limited view of the vocal cords. This is common in emergency and intensive care settings, especially with trauma or critically ill patients. The bougie is a semi-rigid device with a distinct angled tip, which can be guided under the epiglottis and into the trachea. The medical provider can feel the distinctive tactile sensation of the tip passing over the tracheal rings, confirming correct placement before threading the larger endotracheal tube over it. This tactile feedback is a key advantage, reducing the risk of esophageal intubation, which can be fatal.

Indications for Endotracheal Bougie Use

Difficult Airway: When direct laryngoscopy provides a limited view of the glottis (e.g., Cormack-Lehane grade III or IV).
Obscured View: In cases where blood, secretions, or other bodily fluids obstruct the view of the vocal cords.
Difficult Patient Anatomy: Features such as a short neck, obesity, or limited neck mobility can make direct visualization challenging.
First-Pass Strategy: Some clinicians advocate for using a bougie as a standard first-pass technique in emergency intubations due to evidence suggesting improved success rates.

Bougies for Therapeutic Dilation

Another major use of bougies, also known as bougienage or dilation, is to stretch narrowed sections of body passages, most commonly the esophagus. Esophageal strictures can result from chronic acid reflux (GERD), eosinophilic esophagitis, or other conditions. The procedure involves inserting a series of bougies of progressively increasing size to gradually widen the stricture, restoring the ability to swallow effectively.

Indications for Esophageal Bougienage

Peptic Strictures: Caused by chronic acid reflux, leading to scarring and narrowing of the esophagus.
Achalasia: A motility disorder where the lower esophageal sphincter fails to relax properly.
Esophageal Rings and Webs: Thin, concentric membranes of scar tissue that cause narrowing.
Postoperative Strictures: Scarring that occurs after surgical procedures involving the esophagus.
Eosinophilic Esophagitis: Inflammation caused by white blood cells that can lead to scarring and strictures.

Comparison: Bougie vs. Other Dilation Methods

There are several methods for dilating esophageal strictures. The choice depends on the specific characteristics of the narrowing.


Feature	Bougie Dilation	Balloon Dilation
Technique	Tapered, weighted or wire-guided tubes are passed in increasing sizes.	A deflated balloon is inserted endoscopically and inflated to a specific size.
Best For	Simple, multiple, or complex strictures; patients performing self-dilation.	Precise, targeted dilation of single, tight strictures.
Mechanism	Applies gentle, longitudinal pressure through sequential, passive dilation.	Applies radial pressure directly at the stricture site.
Guidance	Can be performed blindly (weighted), with endoscopy, or over a guidewire.	Typically performed under endoscopic and/or fluoroscopic guidance.
Recurrence	Recurrence is possible, sometimes requiring repeat procedures or maintenance.	Similar recurrence rates, often requiring repeat treatments.

Key Considerations and Safety

Regardless of the application, proper technique and patient assessment are paramount when using bougies. For intubation, the tactile sensation must be correctly interpreted to avoid perforation, a rare but serious complication. For dilation, gradual progression is key to minimizing the risk of a tear or perforation of the esophageal wall. The American Gastroenterological Association and other health bodies emphasize careful patient selection and monitoring for these procedures. For further reading, authoritative medical resources like the Cleveland Clinic provide additional insights into dilation procedures.

Conclusion

Bougies are versatile medical tools with important applications in both airway management and therapeutic dilation. Their primary use in intubation is to increase first-attempt success in difficult airway scenarios, while in gastroenterology, they are used to safely widen narrowed passages like the esophagus. The decision on when to use bougies depends on a thorough evaluation of the patient's condition, the specific medical context, and the expertise of the clinician. With proper training and careful technique, bougies remain an invaluable instrument in a medical professional's toolkit, contributing to safer and more effective patient care.

Frequently Asked Questions

A bougie is a hollow introducer with a curved tip used to guide an endotracheal tube into the trachea, relying on tactile feedback when visualization is poor. A stylet is a rigid, malleable wire placed inside the tube to shape it, typically used when the view is adequate.

While traditionally seen as a rescue device for failed intubation attempts, some recent studies and clinicians advocate for using a bougie as a first-line tool, especially in anticipated difficult airways, to increase first-pass success rates.

Bougies are used to treat a variety of conditions causing luminal narrowing, including esophageal strictures from chronic acid reflux, achalasia, esophageal rings, webs, and post-surgical strictures.

The main risks include perforation (a tear in the esophageal wall), bleeding, and aspiration. Careful technique and patient selection are essential to minimize these risks.

The duration of relief varies by patient and condition. While some may achieve long-term results, many patients with recurrent issues may require repeat dilation sessions or maintenance bougienage.

Yes, in select cases with simple and recurrent strictures, patients can be trained to perform self-bougienage at home under strict medical guidance and follow-up. This is done with careful instruction to prevent complications.

Yes, different types of dilating bougies exist, including mercury or tungsten-weighted bougies for blind insertion (though less common now), and wire-guided bougies used in conjunction with fluoroscopy or endoscopy for increased safety and precision.

The "rule of three" is a traditional guideline suggesting that no more than three dilators of incrementally increasing size should be passed during a single dilation session. This is intended to minimize the risk of perforation by preventing overly aggressive stretching.