When intubating patients with anatomically or physiologically challenging airways, first-pass success is of utmost importance to minimize procedural complications (1). According to the INTUBE trial, two or more attempts at intubation were associated with an increased risk for major adverse events (2). Specifically, the risk of severe hypoxemia increased from 5% on the first pass to 20% on the second pass and 30% on the third pass. Let’s examine whether the bougie may be a useful adjunct to improve first-pass success in the Emergency Department (ED) and potentially minimize the risk of severe hypoxemia and other adverse events.
The Data
There are two recent prominent studies examining the use of the bougie in the ED and whether it improves first-pass success:
The BOUGIE trial, released in 2021, was a multi-center randomized control trial (RCT) across 7 EDs and 8 intensive care units (ICUs) across 11 hospitals in the United States, examining 1106 patients undergoing endotracheal (ET) intubation. The patients were randomized into 2 groups: ET intubation with a bougie (n=556) or ET intubation with a malleable stylet and standard geometry blades (n = 546). Both video (75% of intubation attempts) and direct (25% of intubation attempts) laryngoscopy were used. The primary outcome was first-pass success. The secondary outcome was hypoxemia below SpO2 80%. The results showed no significant difference in outcomes with the use of a bougie.
The BEAM trial, released in 2018, was completed at Hennepin County Medical Center in Minneapolis, MN. This was a RCT performed in the ED with 757 patients randomized to 2 groups: ET intubation with a bougie (n=381) or ET intubation with a stylet (n = 376). The primary outcome was first-pass success in patients with at least 1 difficult airway characteristic (i.e. body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or C-spine immobilization). The study found that first-pass success was higher with the bougie (96%) than with the stylet (82%) in patients with difficult airway characteristics.
Discussion
Both studies are both high-powered RCTs with strong data. The BEAM trial focuses more on difficult airways, which emphasizes the importance of the bougie as an adjunct when anticipating challenging intubations. Always having a bougie available, and even reaching for it first when anticipating a poor view or dirty airway may increase your chances of first pass success in the ED.
However, as always, there are limitations to these studies. Regarding the BEAM trial, Hennepin County is known to have a preferred practice of teaching their residents from day one to intubate first with bougie assistance, and nursing and RT are trained to assist the residents in threading the ET tube when the bougie is passed. This practice may introduce some bias into their success rates due to it being their preferred method as an institution. When generalized to other institutions in the BOUGIE trial, the positive effect of the bougie was lost, possibly due to this familiarity bias.
The BOUGIE trial, however, also has its limitations. Their exclusion criteria likely did not allow many difficult airways to be included. Patients requiring emergent intubation were excluded, and any patient who was deemed optimal for hyper-angulated blade use was excluded from the data. Additionally, approximately 45% of patients were intubated for altered mental status, which may suggest that those airways were less emergent and had lower risk of complications or significant pre-existing hypoxemia or cardiovascular distress.
Takeaways
The bougie can be a very useful tool when attempting to intubate, especially when facing a difficult airway. However, familiarity with the tool likely increases one’s ability to successfully intubate with it on the first-pass attempt. At minimum, these trials suggest that practicing with the bougie in simulation and less challenging intubation attempts may help ED physicians become more adept at using it when facing more difficult airways.
Authored by Kathryn McGregor, MD; Taylor Wahrenbrock, MD; and Eric Leser, MD.
Sources
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