Case Presentation: A 72-year-old female presented to the emergency department (ED) with exacerbation of chronic obstructive pulmonary disease and congestive heart failure. The patient required intubation for airway protection and hypercapnic respiratory failure. The ED team used a video laryngoscope, Macintosh 3 blade and bougie as the endotracheal tube delivery device. Despite a grade 2a Cormack-Lehane airway view, the bougie repeatedly missed left posterolateral to the airway. During these missed attempts, the emergency medicine (EM) resident’s shoulder was noted to be abducted. The EM resident then readjusted his technique by adducting the shoulder. which allowed the tip of the bougie to pass the vocal cords resulting in successful intubation.

Discussion: The bougie is a useful endotracheal tube delivery device when used properly. Optimal body mechanics and device orientation are critical to successful use. Shoulder abduction while using the bougie is a frequent mistake, which can lead to left posterolateral malposition in relation to the glottis/airway. In this brief review our goal is to aid the intubating clinician in optimal use of the bougie, yielding more successful endotracheal tube passage.