Option 1: Pass bougie into trachea with a finger in the opening.
(A) Withdraw the scalpel, immediately insert the index finger of the nondominant hand through the horizontal incision and dilate the opening in the cricothyroid membrane. Once the index finger is deeply in the cricothyroid space, it keeps the larynx in place and the surgical pathway into the airway controlled.
(B) Rotate the palm upwards while keeping the index finger inside the rigid cartilaginous structure, keeping it stabilized. Using the volar pad, direct the bougie caudally down the trachea.
Placement of the bougie is confirmed by tactile feedback from the bougie as the tip runs across the anterior tracheal rings (which may not always be appreciated in a stressful situation). Additionally, resistance as the bougie is gently advanced and reaches the carina or mainstem bronchus suggests tracheal placement (but do not advance the bougie too far as perforation of a bronchus or the lung can occur).
Option 2: Pass bougie into trachea with a scalpel in the opening.
(C) An alternative to passing the bougie over the index finger is to leave the scalpel in the wound and use it as a stent to open the incision by gently anchoring the scalpel against the cephalad aspect of the wound.
(D) Insert the bougie through the incision directing it caudally down the trachea.
Placement of the bougie is confirmed by tactile feedback from the bougie as the tip runs across the anterior tracheal rings (which may not always be appreciated in a stressful situation). Additionally, resistance as the bougie is gently advanced and reaches the carina or mainstem bronchus suggests tracheal placement (but do not advance the bougie too far as perforation of a bronchus or the lung can occur).