Bougie vs Endotracheal Tube with Stylet for ED Intubations: an RCT

“…use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation.”

Should we all go bougie first?

As is often the case, the devil is in the details…

This was a single centre clinical trial randomised 757 adult patients to the two arms (bougie vs. stylet) using mostly a C-MAC Macintosh blade.

The primary outcome was first-attempt success in patients with at least one difficult airway characteristics (obesity, short neck, cervical spine immobilisation etc.)

They had a ridiculously high 96% first attempt success rate with the bougie but only an 82% with the stylet. (To put this in perspective, the first attempt success rate in the ANZEDAR registry was 84%)

Before you jump on the gum elastic bougie train, consider a few things.

This study was conducted in an ED where the tradition was to use a bougie first. They would have obviously been more comfortable with this technique and the stylet was new to them.

The vast majority of the intubations were done by less experienced PGY 2 - 4 emergency residents and fellows. Emergency medicine faculty only performed 3% of the procedures.

The incidence of hypoxemia (13% vs. 14%) did not differ between the groups. This is a more relevant patient oriented outcome. This study did not report any patient harms from the lower first-attempt success of the stylet (but to be fair, was not powered for safety).

In the end, I don’t think this study will be overly practice changing. Most clinicians will stick with what they know best. But a 96% first pass success rate is extremely high and hard to ignore.

Covering:

Driver, BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube adn Stylet of First-Attempt Intbuation Success Among Patients with Difficult Airways Undergoing Intubation; A Randomized Clinical Trial. JAMA. 2018;319(21):2179-2189.