Effect of Using a Bougie vs Endotracheal Tube With a Stylet on Successful Intubation in Critically Ill Patients Undergoing Tracheal Intubation
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abstract
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For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.
Objective
To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.
Design, Setting, and Participants
The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.
Interventions
Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).
Main Outcomes and Measures
The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.
Results
Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.
Conclusions and Relevance
Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.
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Additional Info
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Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial
JAMA 2021 Dec 08;[EPub Ahead of Print], BE Driver, MW Semler, WH Self, AA Ginde, SA Trent, S Gandotra, LM Smith, DB Page, DJ Vonderhaar, JR West, AM Joffe, SH Mitchell, KC Doerschug, CG Hughes, K High, JS Landsperger, KE Jackson, MP Howell, SW Robison, JP Gaillard, MR Whitson, CM Barnes, AJ Latimer, VS Koppurapu, BD Alvis, DW Russell, KW Gibbs, L Wang, CJ Lindsell, DR Janz, TW Rice, ME Prekker, JD CaseyFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
It is well established that critically ill patients who require intubation have a higher complication rate and lower first-pass success rate compared with a stable patient in the perioperative suite. The reasons are multifactorial but include concurrent severe physiologic derangement, patient-related factors, heterogeneity of available equipment, as well as staff expertise. Prior small studies have examined the utility of routine incorporation of airway adjuncts, such as a bougie. In this large randomized controlled study, over 1100 patients were randomized to either be intubated with a bougie on first laryngoscopy attempt or with a standard endotracheal tube with stylet. The vast majority of intubations were performed by trainees (resident or fellow; close to 95% in both arms) with about three-quarters performed using a video laryngoscope. The average operator had performed a median of 60 prior intubations prior to involvement in this trial. Results showed that there was no significant difference in successful intubation on first attempt or adverse events. The trial excluded patients for whom intubation was deemed truly emergent (eg, cardiac arrest), in those who were being intubated with a hyperangulated blade, as well as in those with concern for abnormal airway anatomy. Most primary operators also had limited previous experience intubating using a bougie. Further study is needed to identify whether there is a specific subset in which a "bougie first" approach is safer; but, based on the study findings, routine use for all-comers is not indicated.