This week Dr. Morganstern posted Bougie is better (Driver 2018): Should we use a bougie routinely for our first attempt at intubation? June 27, 2018. In this post, Dr. Morganstern reviews the article 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. [PubMed Abstract]. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496.
You’ll also want to review Dr. Weingart’s post and podcast EMCrit Podcast 226 – Airway Update – Bougie and Positioning June 13, 2018 by Dr. Scott Weingart.
Dr. Morganstern reviews the article and here are some of his thoughts:
757 patients were randomized, 380 of whom had a difficult airway characteristic.
Primary outcome: First pass success among patients with a difficult airway characteristic was 96% with the bougie and 82% with the endotracheal tube plus stylet (absolute difference of 14%, 95%CI 8-20%, NNT= 7, p<0.001).
The bougie first approach was also better in all comers (98% success vs 87%, ARR 11%, 95% CI 7-14%, p<0.001)
Complications were the same in both groups (17% vs 17%, p=0.83). Hypoxia occured in 13% with the bougie and 14% with the stylet (p=0.67). There was no extra trauma with the bougie.
There were 3 esophageal intubations with the endotracheal tube and stylet versus 0 with the bougie (p=0.08)
Although it may bother some people in the FOAM world who love to pre-load their bougie, the technique studied here, and therefore the technique with the best evidence base, is the classic technique: intubate with just the bougie, and then load the endotracheal tube over the bougie after it is through the cords.
Personally, I think this will change by practice. To date, I have only been using the bougie as a rescue technique, or in patients with a predicted difficult airway. This is the best study we have to day, and based on the clear benefit to using the bougie demonstrated here, I will likely start routinely intubating with a bougie on the first attempt.