Endotracheal intubation with a gum-elastic bougie in unanticipated difficult direct laryngoscopy: Comparison of a blind technique versus indirect laryngoscopy with a laryngeal mirror

We evaluated the efficacy of intubation over a gumelastic bougie by using either a blind technique or indirect laryngoscopy with a laryngeal mirror in patients with unexpected difficult direct laryngoscopy. In a prospective study, 60 consecutive patients with an unexpected Grade III or IV direct laryngoscopy were randomly allocated for intubation with a gum-elastic bougie either blindly (Group 1) or by indirect laryngoscopy with a laryngeal mirror (Group 2). We evaluated the failure rate of each method of intubation, complications related to either method, and the time required for intubation. Out of 725 patients evaluated over a 2-mo period, 60 patients (8.3%) had a Grade III laryngoscopy, and 30 of these were randomized into each group. There were 8 failed intubations in Group 1 compared with 1 failed intubation in Group 2 (P < 0.05). All eight failures in the blind intubation group ended with esophageal intubation. No additional complications were noted in either group. The time required for endotracheal intubation with each group was not significantly different (45 ± 10 s versus 44 ± 11 s). We conclude that intubation with a gum-elastic bougie had a lower failure rate using indirect laryngoscopy with a laryngeal mirror than a traditional blind technique.