Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation
Hypothesis: Bougie use will facilitate higher first-pass intubation success than an endotracheal tube with stylet among patients with a difficult airway characteristic.
Methods: All patients 18 years or older where the initial plan was to attempt direct laryngoscopy (DL) with a Macintosh blade at an academic level 1 trauma center were included. Patients excluded were those pregnant, known to have distortions of the airway, or prisoners. All patients were intubated by EM residents, fellows, and attending physicians with a 1:1 randomized application of DL with bougie vs. DL with ETT and stylet. After intubation, the provider would record if the patient had difficult airway characteristics without strict criteria.
Results: First pass success with DL + bougie was 96% compared to 82% with ETT with a stylet (P < 0.001) without a significant difference in the duration of intubation attempts. Secondary analysis suggested that patients with a Cormack 2-3 view initially had improved views with use of a bougie.
Strengths
RCT with sample size in the hundreds,
ITT analysis
Simple study design
Weaknesses
Operators not blinded to intubating device
Subjective assessment of difficult airway characteristics
Single institution study
Institution had a history of routine bougie use
No standard induction doses
Key Point: Use of a bougie was associated with a greater first-attempt success rate compared to using an endotracheal tube with a stylet without changes in time to intubation or complications.