The Bougie Is Your Airway Management Safety Net

Bougie airway intubations - endotracheal stylet Over 400,000 Americans are intubated in emergency settings annually for various reasons—about 12.7% of them are unsuccessful on the first attempt. 

Failure to intubate the trachea on the first try occurs in up to 20% of cases. To make matters worse, it is associated with severe hypoxemia and cardiac arrest. Moreover, it has been found to increase the likelihood of many other adverse events, including aspiration, trauma to soft tissue, dysrhythmia, and hypotension. 

Given how much it can affect clinical outcomes, it’s unsurprising that there is an ongoing debate in the healthcare community over the best method for successful intubation—whether it’s bougie vs endotracheal tube with stylet. 

And that’s where things get tricky. 

The Bougie Use in Emergency Airway Management (BEAM) trial published in 2018 showed that the bougie airway had a 96% first-attempt emergency intubation success compared to 82% for the endotracheal tube with stylet for patients with difficult airways. 

However, this wasn’t reflected in the consequent trial by the same network.  

So, what’s the verdict? 

Which equipment do you use to deliver top-of-the-line patient care? Get research and evidence-based insights with Hospital Procedure Consultancy, where you can take live courses to develop your procedural skills with the guidance of skilled educators. 

Summarizing the Current Literature on Successful Methods of Intubation 

The “Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE)” was a multi-center, parallel-group, unblinded, randomized clinical trial involving critically ill adult patients from 7 emergency departments and 8 ICUs across the U.S.

Exclusion Criteria 

Out of the 1,558 patients screened, only 71% (1,106) were enrolled in the analysis. 

Eighty-one of those excluded did not meet the inclusion criteria; the remaining 371 —

  • Were younger than 18 years
  • Had bougie or stylet required or contraindicated
  • Were eligible, but not enrolled for various reasons
  • Underwent intubation too urgently to wait for randomization

In addition, pregnant women and prisoners were also withdrawn from the trial.

Operators and Trial Interventions 

Operators were selected through criteria that prioritized experience and expertise. 

So, it’s not surprising that 61.6% of operators were resident physicians whose most common specialty (62.9%) was emergency medicine. Both had performed a median of 60 prior intubations, with a median of 10 with a bougie airway. 

Before the study, they received structured education via a standardized training video and in-person training from the principal investigator. 

Outcomes and Results 

The primary outcome was a first-pass success, defined as a single insertion of a laryngoscope into the mouth followed by a single insertion of the device (bougie, endotracheal tube, or endotracheal tube+stylet) to which the patient was randomized. 

Success was observed in 80.4% of the bougie group vs 83% of the stylet group. 

As is evident, the use of bougie did not substantially increase successful intubation upon the first attempt. This remained true across different parameters. For example, it also found that the median time to intubate was 2 minutes and 4 seconds for the bougie group vs 1 minute and 52 seconds for the stylet group. Meanwhile, hypoxia occurred in 11% of the former group vs 9% of the stylet.

So, Which One Is Better? Understanding BOUGIE vs. BEAM

Unfortunately, this is not an either-or use case.

The BEAM trial, as evidenced, favored the bougie over stylet by an impressive 14%. However, the BOUGIE trial showed no significant difference between the two tools, but this could be because of its strict criteria regarding what’s considered a successful procedure. It was defined as “a single insertion of both the blade and the bougie or tube.” 

As such, the distinction boils down to what’s best for the patient.

And that’s where bougie airway reigns supreme. 

It remains the preferred method among emergency healthcare providers as the thin plastic rod passes through the vocal cords easily. A recent trial also found that it has a higher first-pass success for Pragmatic Airway Resuscitation. It can be used to assist with intubation through a Laryngeal Mask Airway (LMA) and is the preferred approach for cricothyrotomy for anatomically difficult intubation. Few instances of complications have been reported over the years and it’s generally viewed as safe.

An endotracheal tube, on the other hand, is placed between the vocal cords through the trachea, acting as a conduit for respiration and other lung therapies. It can have many complications, from hoarseness to laryngeal injury and laryngotracheal stenosis. 

These findings were replicated by a May 2021 randomized clinical trial. Conducted in 32 intensive care units on 999 patients, 200 patients (40.2%) in the tracheal tube group suffered complications related to tracheal intubation. But when a stylet was introduced to the other group, the risk dipped by 1.5% and first-attempt intubation success was up by 6.7%!

This goes to show that a stylet could also be useful in airway management, but it’s more setting-oriented (ICU or otherwise) than patient-characteristics-centered. 

Learn How To Insert a Bougie on the First Attempt With HPC

Even in the BOUGIE trial, a video laryngoscope was used for more than three-quarters (75.7%) of patients in the bougie group and 73.8% of patients in the stylet group. The tool is slender and firm, with tips that rotate with a clinically acceptable rotational force so it can easily be slid into place. However, the placement of tracheal introducers has been known to cause airway injuries.

Since research shows that intubation-related complications are higher among inexperienced operators of video laryngoscope devices, it’s important to practice with a gum-elastic bougie which is thinner and more flexible. It is known to enable shorter intubation times and higher intubation success rates among those with difficult airways—even in infants. With routine use, it can increase the first-attempt success rate for paramedics who use them in out-of-hospital settings.

Hence, in endotracheal intubation situations where you can’t see the cords, the bougie is your friend. Learn how to use it—and how to use it right with Hospital Procedures Consultants.


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Tags: airway management, Bougie airway intubations

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