[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [The airway](https://durgical.com/en/anaesthesia/areas/airway/) › Videolaryngoscopy, bougies and other adjuncts

# Videolaryngoscopy, bougies and other adjuncts

- Technique

A laryngoscope with a camera at the blade tip, plus simple tools such as a bougie, that help pass a breathing tube when the larynx is hard to see.

Updated Nov 13, 2026

## Key points

- Videolaryngoscopy improves the glottic view and first-pass success, mainly in difficult airways; many guidelines now advise it be available for every intubation.
- Hyperangulated blades need a preshaped rigid stylet: «good view, but cannot pass the tube» is the typical problem.
- Bougie in the trachea: clicks over the tracheal rings and a hold-up in a small bronchus; in the oesophagus neither happens.
- Railroad the tube over the bougie while rotating it anticlockwise so the bevel does not catch on the right arytenoid.
- Watch the tube enter the mouth and pharynx before looking at the screen, to avoid palate and tonsil injury.

On this page

- The basics Key points
- What it is
- Indications
- Equipment and preparation
- Step by step (and why)
- Common airway adjuncts and what they are for
- Next step
- Elsewhere in DurgiPedia

- Clinical Complications

- Safety Contraindications and precautions

- Study Test yourself

- Connections Connections

## What it is

A videolaryngoscope carries a small camera near the tip of its blade and shows the larynx on a screen, so the operator looks around the curve of the tongue instead of needing a straight line of sight from the mouth to the glottis. Blades come in two broad shapes: standard-geometry blades, shaped like the usual curved blade, which allow both a direct and a screen view and suit routine use and teaching; and hyperangulated blades, which give a better view of an anterior larynx but need a tube shaped by a rigid stylet to follow the steep curve. Compared with direct laryngoscopy, videolaryngoscopy improves the glottic view and the first-attempt success, especially in difficult airways and in less experienced hands, needs less neck movement and lets the whole team see. Its weak points are that seeing the glottis does not always mean the tube will pass, blood, secretions or fogging can blind the camera, and pushing the tube in blindly can injure the palate or tonsils. Simple adjuncts remain essential: the bougie (a long flexible introducer with an angled tip), the malleable stylet, external laryngeal manipulation and the supraglottic airway as a rescue and as a channel for intubation.

## Indications

- Predicted or known difficult airway, including limited neck movement and a small mouth with prominent teeth.
- Suspected cervical spine injury, where less neck movement is wanted.
- Rescue after a failed or poor direct view (Cormack–Lehane grade 3 or 4).
- Obesity, emergency and intensive care intubations, where first-pass success matters most.
- Teaching and supervision: the trainer sees the same view as the trainee.

## Contraindications and precautions

- Blood, vomit or heavy secretions can hide the camera: suction first and keep direct laryngoscopy ready.
- Very limited mouth opening may not admit the blade; consider awake flexible bronchoscopic intubation.
- Hyperangulated blades are hard to use without a stylet and with little practice; use the blade you train with.
- A bougie is passed gently: forcing it can perforate the airway or oesophagus.
- Keep the device charged, cleaned and checked; a blank screen at induction is a preventable crisis.

## Equipment and preparation

- Videolaryngoscope with standard-geometry and hyperangulated blades, charged and with a working screen.
- Rigid or malleable stylet shaped to match the chosen blade.
- Bougie (tracheal tube introducer) and tubes in the chosen size and smaller.
- Supraglottic airway (laryngeal mask type, second generation) as rescue and intubation conduit.
- Flexible bronchoscope for awake or conduit intubation, anti-fog measures, suction and capnography.

## Step by step (and why)

- Choose the blade before induction and shape the tube to it — a hyperangulated blade needs a steeply curved stylet.
- Insert the blade in the midline and follow the tongue while watching the mouth — this avoids injuring the lips and teeth.
- Look at the screen and aim to see the glottis in the upper half of the image — too close a view leaves no room to steer the tube.
- Pass the tube into the mouth under direct vision until its tip appears on screen — blind insertion can tear the palate or tonsils.
- If the tube hits the anterior wall, pull the blade back slightly and withdraw the stylet a little — this flattens the angle.
- If the view is poor, try external laryngeal pressure on the thyroid cartilage — moving the larynx brings the glottis into view.
- Pass a bougie when only the epiglottis or arytenoids are seen, feeling for clicks or hold-up — these confirm tracheal placement.
- Keep the laryngoscope in place and railroad the tube over the bougie, rotating it anticlockwise — the bevel slides past the arytenoids.
- Confirm with waveform capnography as always — a good screen view does not prove tracheal placement.

## Common airway adjuncts and what they are for

| Adjunct | What it does | Tip |
| --- | --- | --- |
| Bougie | Long flexible introducer with an angled tip; guides the tube into the trachea | Feel clicks or hold-up; railroad the tube with anticlockwise rotation |
| Stylet | Malleable or rigid rod that shapes the tube | Tip must stay inside the tube; withdraw it as the tube enters the cords |
| External laryngeal manipulation | Pressure on the thyroid cartilage backwards, upwards and to the right | The operator guides the assistant's hand to the best view |
| Supraglottic airway | Sits over the larynx to oxygenate; some allow intubation through them | Rescue oxygenation after failed intubation |
| Flexible bronchoscope | Steerable scope that guides the tube under vision | Awake intubation or through a supraglottic airway |

## Complications

- Injury to the soft palate, tonsillar pillars or pharynx from blind tube advancement.
- Delay and desaturation while trying to steer a tube toward a well-seen glottis.
- Fogged or soiled camera leading to loss of view; switch to suction, another blade or direct laryngoscopy.
- Airway trauma, bleeding or perforation from a bougie or stylet pushed with force.
- Fixation on one device: repeated attempts instead of moving to the next step of the difficult-airway plan.

## Next step

- Practise on manikins and in routine cases with the same videolaryngoscope used in emergencies.
- After two failed attempts with any device, call for senior help and move to the next step of the difficult-airway plan.
- Document the device, blade, view, adjuncts used and number of attempts.
- Check the oropharynx for bleeding or injury after a difficult insertion and warn the patient of possible sore throat.

## Test yourself

Think of the answer, then tap the question to see it.

## What is the main advantage of a videolaryngoscope over direct laryngoscopy?

It shows the glottis without a straight line of sight, so it improves the view and first-attempt success, especially in difficult airways, with less neck movement.

## Why does a hyperangulated blade need a preshaped stylet?

The blade sees around a steep curve; a straight tube cannot follow it, so the tube is shaped to the same curve with a rigid stylet.

## How can a bougie tell the trachea from the oesophagus?

In the trachea it clicks over the cartilage rings and stops (hold-up) in a small bronchus; in the oesophagus it passes smoothly without clicks or hold-up.

## How is palate injury avoided when using a videolaryngoscope?

The tube is watched directly as it enters the mouth and pharynx, and the operator looks at the screen only once the tube tip appears on it.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/videolaryngoscopy-bougies-and-other-adjuncts/)

## Elsewhere in DurgiPedia

- [Supraglottic airway devices](https://durgical.com/en/clinical-skills/supraglottic-airway-devices/)
- [Bronchoscopy](https://durgical.com/en/clinical-skills/bronchoscopy/)

## Connections

## Related 5

- [Tracheal intubation](https://durgical.com/en/anaesthesia/tracheal-intubation/)
- [The unanticipated difficult airway: plans A to D](https://durgical.com/en/anaesthesia/the-unanticipated-difficult-airway-plans-a-to-d/)
- [Predicting a difficult airway: Mallampati, mouth opening, neck and jaw](https://durgical.com/en/anaesthesia/predicting-a-difficult-airway-mallampati-mouth-opening-neck-and-jaw/)
- [Rapid-sequence induction and intubation](https://durgical.com/en/anaesthesia/rapid-sequence-induction-and-intubation/)
- [Cannot intubate, cannot oxygenate: front-of-neck access](https://durgical.com/en/anaesthesia/cannot-intubate-cannot-oxygenate-front-of-neck-access/)

## Related conditions 3

- [Obesity](https://durgical.com/en/conditions/obesity/)
- [Ankylosing spondylitis](https://durgical.com/en/conditions/ankylosing-spondylitis/)
- [Rheumatoid arthritis](https://durgical.com/en/conditions/rheumatoid-arthritis/)

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Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Video Laryngoscopy](https://www.ncbi.nlm.nih.gov/books/NBK623720/) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/anaesthesia/videolaryngoscopy-bougies-and-other-adjuncts/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/videolaryngoscopy-bougies-and-other-adjuncts/