The Difficult Airway: Bougie, Rescue Devices & Front-of-Neck Access

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Updated July 2026  |  More ICU nursing guides →

Most intubations are routine. A minority are not, and the difference between a difficult airway that ends well and one that ends in catastrophe is often how prepared the room was before the first attempt — which is largely a nursing job. You will not be the one passing a bougie or making an incision in the neck, but you will be the one who has the rescue equipment open and reachable, who tracks the failed attempts, and who says the words that trigger the next step in the algorithm. This is a map of that terrain.

Predicting the difficult airway

The team tries to identify a difficult airway before committing, because a planned awake or double-setup approach is far safer than discovering the problem after the patient is paralyzed. A common screen is the LEMON assessment. Knowing it helps you anticipate what equipment to pull.

When any of these flags a hard airway, the plan changes: the most experienced operator takes the first look, video laryngoscopy is the default rather than direct, and — critically — the surgical airway kit is opened and a "double setup" is declared so that front-of-neck access can begin within seconds if needed.

The bougie: the simplest rescue in the room

The bougie (a bougie or tracheal tube introducer) is a long, semi-rigid stylet with an angled "coudé" tip. When the laryngoscopic view is poor and the operator can see only the epiglottis but not the cords, the bougie is slid underneath the epiglottis into the trachea; the angled tip catches on the tracheal rings — the operator feels the "clicks" — and confirms tracheal placement, and the endotracheal tube is then railroaded over it. It is cheap, fast, and rescues a large share of difficult views. Many units now use a bougie on the first attempt for any anticipated difficulty rather than as a bailout. Have it open and handed at the ready whenever the airway looks hard.

Video laryngoscopy and the escalation ladder

Video laryngoscopy — a camera at the blade tip displaying the glottis on a screen — has become the default for difficult and often routine airways because it improves the view without needing to align the axes as precisely as direct laryngoscopy. The nurse's job is to have it charged, the correct blade attached, and the screen positioned so the operator can see it. When attempts fail, the team moves down a ladder, and each rung has an equipment implication you can stay ahead of:

1. Optimize and re-attempt: reposition, external laryngeal manipulation, bougie, different blade — but limit attempts.
2. Bag-valve-mask to re-oxygenate between attempts — this is the pause that prevents desaturation-driven arrest.
3. Supraglottic rescue device (e.g., a laryngeal mask airway) to oxygenate when intubation fails.
4. Front-of-neck access if the patient cannot be intubated and cannot be oxygenated.

The supraglottic airway: buying oxygenation

When the tube will not pass but the patient can still be oxygenated, a supraglottic airway — most commonly a laryngeal mask airway (LMA) — sits above the glottis and provides a route to ventilate without passing through the cords. It does not definitively protect against aspiration the way an endotracheal tube does, but in the failed airway it converts a can't-intubate situation into a can-oxygenate one, which buys time to plan. Keep the correct sizes immediately available in the airway cart.

Can't intubate, can't oxygenate (CICO): front-of-neck access

The true airway emergency is can't intubate, can't oxygenate (CICO) — the tube won't pass, the mask won't move air, the LMA fails, and the saturation is falling toward an arrest. This is the scenario the double-setup existed for. The definitive rescue is front-of-neck access (FONA) — an emergency surgical airway (cricothyrotomy) placed through the cricothyroid membrane by a qualified provider. It is rare and it is frightening, and it goes better when the equipment is already open. The nurse's contribution in a CICO event is fast and specific: get the surgical airway kit open and handed, call for additional help (anesthesia, surgery, a second provider), keep apneic oxygen flowing at the nose, prepare code medications, and keep an accurate clock — everyone loses time-sense in these moments, and the nurse announcing elapsed time drives the tempo.

This completes the airway series. Start with the ICU nurse's role in RSI, keep the patient oxygenated with preoxygenation and apneic oxygenation, and prevent the crash with peri-intubation hemodynamics.