Which Is Better For First Pass Intubation Success – The Bougie Or The Endotracheal Tube and Stylet

Dr. Morganstern‘s emergency medicine blog, First10EM, is excellent. You might want to go to the blog and sign up by email to follow the blog and receive notification of new posts by email.

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.

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