Should You Use A Bougie or An Endotracheal Tube And Stylet On Your First Attempt Emergency Intubation?

Dr. Rory Spiegel of EM Nerd [Link is to Dr. Spiegel’s archives] in his post  EM Nerd-The Peculiar Case of the Parallel Pathways [Link is to Dr. Spiegel’s post] May 18, 2018, reviews and endorses the recent study Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial [Link is to the Abstract].

Dr. Spiegel’s review of the article agrees with the conclusion of the article and he believes that it is clinically applicable to real-life emergency practice.

What follows are excerpts from Dr. Spiegel’s post:

So rarely is a study published that directly and effortlessly translates into clinical practice. Very few of these studies examine the nuances of everyday practice in the fast paced milieu of the Emergency Department. Given the infrequency of such studies, I am continually amazed by the work put forth by Brian Driver* and colleagues at the Hennepin County Emergency Department.

*This link is to Dr. Driver’s biography on the Hennepin Healthcare site. When I visited Dr. Driver’s page, I was so blown away by the other useful  research articles that he has published, that I have listed those articles in Additional Resources below.

The most recent of his clinical gems, Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation, A Randomized Clinical Trial, was just published in JAMA.

The authors enrolled a total of 757 patients. Of these, 380 were determined to have at least one difficulty airway characteristic (defined as body fluid(s) obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or cervical spine immobilization). In patients randomized to the bougie-first approach, the authors found a 14% absolute increase in their primary outcome, the rate of first pass success in patients with at least one difficulty airway characteristic. A similar 11% absolute benefit in favor of the bougie-first method was noted in the entire 757 patient cohort. Even in the subset of patients who were not predicted to be a difficult airway, a 7% absolute increase in the rate of FPS was observed. In fact, the authors were unable to find any interaction between the presence of difficult airway predictors and efficacy of the bougie. The bougie also proved itself superior to the traditional ETT and stylet approach in a number of subsets of patients, including patients requiring cervical in-line immobilization (100% vs 78%,), obese patients (96% vs 75%), and patients with incomplete glottic views on laryngoscopy corresponding to Cormack-Lehane grades 2 to 4 (97% vs 60%).

The Driver et al study also serves to discredit some of the arguments commonly cited against the use of a bougie-first strategy. For instance, It takes longer to intubate the patient, which will lead to a clinically significant amount of needless desaturation events. Overall time to intubation was far shorter in the patients that were randomized to the bougie-first strategy. This temporal benefit was entirely powered by the higher rate of FPS observed in the bougie-first group. When the authors examined the subset of patients who were successfully intubated on first attempt, they noted a 4-second delay in time to intubation associated with the use of the bougie. And while this difference is statistically significant it has little clinical meaning especially given the overall improvement in FPS. In addition even this small difference in time to intubation is likely to be avoided by any of the many preloaded bougie techniques which were not utilized in this study, but provide a much swifter tube delivery mechanism. The bougie can cause an airway injury as its distal tip is wedged in the small airways during the intubation process. The authors found no difference in overall complication rate, the rate of direct airway trauma, or the incidence of pneumothorax following intubation. There is often significant difficulty passing the tube over a bougie, as it will frequently get stuck in the arytenoid cartilages. Resistance to tube passage occurred in only 7% of patients, and all but one was resolved by simply turning the tube 90 degrees counter-clockwise prior to insertion.

This study also beautifully compliments Drs. Helman and Weingart’s recent podcast,  Ep 110 Airway Pitfalls – Live from EMU 2018, in which Dr. Weingart recommends the use of video laryngoscopy along with the use of a bougie.

Additional Resources

(1) Driver, B.E. and McGill, J.W., 2017. Emergency Department Airway Management of Severe Angioedema: A Video Review of 45 Intubations. Annals of Emergency Medicine. 2017: In Press

(2) Driver BE, Reardon RF. Apnea After Low-Dose Ketamine Sedation During Attempted Delayed Sequence Intubation. Annals of Emergency Medicine. 2017: 69(1), pp.34-35.

(3) Driver BE, Plummer D, Heegaard W, Reardon RF. Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure. The Journal of Emergency Medicine. 2016: 51(6), pp.e133-e135.

(4) Driver BE, Prekker ME, Kornas RL, Cales EK, Reardon RF. Flush Rate Oxygen for Emergency Airway Preoxygenation. Annals of Emergency Medicine 2017; 69(1);1-6.

(5) Driver BE, Shroff GR, and Smith SW. Posterior reperfusion T-waves: Wellens’ syndrome of the posterior wall. Emergency Medicine Journal (2016): emermed-2016. In Press.

(6) Driver BE, Olives TD, Bischof JE, Salmen MR, Miner JR. Discharge Glucose Is Not Associated With Short-Term Adverse Outcomes in Emergency Department Patients With Moderate to Severe Hyperglycemia. Annals of emergency medicine. 2016 Dec 31;68(6):697-705.

(7) Dodd KW, Klein LR, Kornas RL, Driver BE, Ho JD, Reardon RF. Definitive airway management in emergency department patients with a King laryngeal tube™ in place: a simple and safe approach. Canadian Journal of Anesthesia/Journal canadien d’anesthésie. 2016 Jan 25:1-2.

(8) Driver BE, Prekker ME, Moore JC, Schick A, Reardon RF, Miner JR. Direct versus Video Laryngoscopy using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Acad Emerg Med. In press.

(9) O’Brien Lambert, A., Driver, B., Moore, J.C., Schick, A. and Miner, J.R., 2016. Using Near Infrared Spectroscopy for Tissue Oxygenation Monitoring During Procedural Sedation: The Occurrence of Peripheral Tissue Oxygenation Changes With Respiratory Depression and Supportive Airway Measures. Academic Emergency Medicine, 23(1), pp.98-101.

(10) Smetana A, Driver B, Gajic S, Smith S. Partial segmental thrombosis of the corpus cavernosum presenting to the ED: 2 case reports. The American Journal of Emergency Medicine. October 2015. doi:10.1016/j.ajem.2015.10.040.

(11) White S, Driver BE, Cole JB. Metformin-Associated Lactic Acidosis Presenting as Acute ST Elevation Myocardial Infarction. J Emerg Med. October 2015. doi:10.1016/j.jemermed.2015.10.012.

(12) Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014;85(10):1337-1341, doi:10.1016/j.resuscitation.2014.06.032

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