I consider myself a disciple of the bougie, and I was eagerly awaiting the findings of the first multicenter randomized controlled trial to confirm my success with it.
Much to my dismay, the BOUGIE trial found no difference in first-pass success in intubation between two groups—80.4 percent for the bougie v. 83 percent for the stylet (p=0.27). The study also showed no difference in the incidence of hypoxia or procedural complications.
Is it time to throw out the bougie? Like most things in evidence-based medicine, the answer is complicated.
The BEAM Trial
I have primarily used the bougie throughout my short career in emergency medicine, and it has reliably produced excellent results in my overall intubation success. I’ve relentlessly advocated for its use, and have turned a handful of my resident-colleagues into faithful acolytes.
The BEAM trial (Bougie Use in Emergency Airway Management) had a profound impact on my approach toward airway management. (JAMA. 2018;319:2179; https://bityl.co/D2bD.) It showed a 98 percent first-pass success in intubation with a bougie compared with 87 percent with a stylet. The results were impressive, but it was performed in a single emergency department where bougie use was the norm. Its results were ripe to be confirmed with a larger multicenter study to bolster its generalizability.
Enter the BOUGIE trial. The Bougie or Stylet in Patients Undergoing Intubation Emergently trial evaluated the effect of the bougie on first-pass success in intubation. (JAMA. 2021;326:2488; https://bityl.co/D2bF.) It randomized 1102 patients in 15 emergency departments and ICUs at nine hospitals to undergo intubation with a bougie or an endotracheal tube loaded over a stylet. Their median age was 58, and 41 percent of the patients were women. Sixty percent of the intubations occurred in the ED and 40 percent in the ICU.
In Defense of the Bougie
This was a well-done study with valid results, but it is worth considering why the BEAM trial produced such impressive results and the BOUGIE trial failed to replicate them.
The BEAM trial was conducted at Hennepin County Medical Center where residents are trained to use the bougie for their first pass in intubation. Fourteen of the 15 EDs and ICUs in the BOUGIE trial, however, used a bougie on the first attempt “sometimes” or “rarely” prior to the study. What’s more, the median number of attempts with a bougie per proceduralist before the study was only 10. So limited experience with the bougie likely contributed to its lack of efficacy in this study. You have to use it if you want the bougie to work for you!
Another interesting limitation can be found in the supplement to the paper. Eleven of those 15 EDs and ICUs formed a bend in the bougie before intubation “sometimes” or “rarely.” I find it difficult to pass a straight bougie through the vocal cords (imagine trying to pass an endotracheal tube with a straight stylet), and recommend forming a slight bend to allow it to follow the natural curvature of the oro- and hypopharyngeal structures.
The trial protocol encouraged forming a 25- to 35-degree bend in the stylet to facilitate intubation, which is considered standard practice. (BMJOpen. 2021;11:e047790; https://bityl.co/D2bL.) But it did not recommend forming a similar curvature with the bougie—this was left up to the physician doing the procedure—so the trial authors likely introduced bias against the bougie group.
Finding the Best Approach
The stylet group in the BEAM trial had a success rate of 87 percent compared with the low 80s for each group in the BOUGIE trial. This difference can be accounted for by the differing definitions of a single attempt in each trial. The BEAM trial defined an attempt as each insertion of the laryngoscope blade, while the BOUGIE trial defined an attempt as each insertion of the bougie or stylet. The success rate matched that of the stylet group in the BEAM trial at 87 percent when the BOUGIE authors reanalyzed their data according to the BEAM definition of one attempt.
The emergency physicians in the BEAM trial were still able to match their success rate with a stylet to that of the BOUGIE participants despite learning intubation primarily with a bougie. It may be possible to replicate the high first-pass success of the BEAM trial (98%) with a bougie if this device is your preferred method of intubation during training. What’s more, success with a stylet will likely be unaffected by this approach. The inverse is unlikely to be true if you choose to use a stylet primarily.
I still have faith in the bougie. In fact, the BOUGIE trial confirmed what I already thought to be true: The bougie is no magic bullet, and you will only find success with it if you use it! This nifty little device has allowed me to confidently intubate patients when otherwise I would have been holding my breath in anxious anticipation of the end-tidal COtwo waveform. I encourage you to experiment not only with the bougie but all airway adjuncts to find out what approach works best for you.
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dr cunninghamcompleted his emergency medicine residency at Maricopa Medical Center in Phoenix, and is currently a critical care fellow at Stanford Medical Center in Palo Alto. Follow him on Twitter@HappyDays_EM.