Bougie so Bougie
/Driver, B. E. et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation. Jama 326, 2488–2497 (2021).
Background
Several studies have shown that first pass intubation rate in the emergency department and ICU are approximately 80%. We know that failure on initial intubation attempt is associated with higher rates of hypoxemia, cardiac arrest, and death. A previous study entitled Bougie Use in Emergency Airway Management (BEAM, Driver et al., 2018) showed that the use of a bougie may increase first pass intubation success rates, however this was a single center study performed at a location where bougie use is the standard of care. This study aimed to examine if this finding is generalizable to a broader population.
Methods
This study was an unblinded, randomized controlled trial in which both emergency and ICU providers across 15 sites were randomized to either using a bougie or flexible stylet for first pass intubation. Patients undergoing planned intubation with use of sedation and a nonhyperangulated blade were eligible for the study. Exclusion criteria included pregnant patients, incarcerated patients, patients for whom emergent intubation was needed without time for randomization, and cases in which either the bougie or stylet were contraindicated for anatomic or other reasons as determined by the provider. Providers were trained on both bougie and stylet assisted intubation prior to the study.
The primary outcome of the study was first pass intubation which was defined by one insertion of the blade and one attempt at passing the endotracheal tube. The secondary outcome was incidence of severe hypoxemia which was defined as oxygen saturation less than 80% between induction and up to 2 minutes after intubation. Multiple other data points were also taken into account including but not limited to demographic intubation, provider experience with intubation, time between attempts, difficult airway characteristics, and any complications seen.
Results
A total of 1558 patients were screened and 1102 patients ultimately enrolled in the study. There was no significant difference between successful first pass intubation between the two groups with 80.4% success rate in the bougie group compared to 83% first pass success in the stylet group. As for the secondary outcome of extreme hypoxemia, again the two groups were not significantly different. Interestingly, there was a longer time from induction to intubation in the bougie group. There was also a statistically significant higher rate of cardiovascular collapse and death prior to 28 days in the stylet group, however given that there was no difference in intubation it is difficult to determine if this is clinically significant.
Limitations
There are several important limitations to consider when assessing the BOUGIE study. First, the study was unblinded which may lead to bias on the part of providers. Second, the study excluded any emergent intubations or intubations for which providers believed that either the bougie or stylet were contraindicated which may also bias the results. Finally, first pass success is only a surrogate for clinical outcomes, therefore further studies would have to be performed to determine true clinical significance.
Conclusion
The BOUGIE trial did not find any significant difference on first pass intubation or hypoxemia between those using a bougie or stylet for endotracheal intubation, a result that contradicts the original BEAM trial. These results in conjunction with those of the BEAM trial show that while bougie may improve intubation rates in experienced providers, this does not carry over into providers who do not regularly use the bougie. We should all continue to utilize different airway devices to become facile in as many tools as possible.
Authorship
Written by: Bailee Stark, PGY-3, University of Cincinnati Department of Emergency Medicine
Peer Review, Editing, Posting by: Jeffery Hill, MD MEd, Associate Professor, University of Cincinnati Department of Emergency Medicine
Cite As
Stark, B. Hill, J. (August 24, 2022). Bougie so Bougie. TamingtheSRU. https://www.tamingthesru.com/blog/2022/8/24/bougie-so-bougie
