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Original Investigation
Caring for the Critically Ill Patient
December 8, 2021

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

Author Affiliations
  • 1Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
  • 2Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
  • 3Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
  • 4Vanderbilt Institute for Clinical and Translational Sciences, Nashville, Tennessee
  • 5Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
  • 6Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
  • 7Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham
  • 8Department of Emergency Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina
  • 9Department of Emergency Medicine, University of Alabama at Birmingham
  • 10Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
  • 11Section of Emergency Medicine, Louisiana State University School of Medicine, New Orleans
  • 12Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
  • 13Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
  • 14Department of Emergency Medicine, University of Washington, Seattle
  • 15Department of Internal Medicine, University of Iowa, Iowa City
  • 16Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
  • 17Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
  • 18Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina
  • 19Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
  • 20University Medical Center New Orleans, New Orleans, Louisiana
  • 21Section of Pulmonary/Critical Care Medicine & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans
  • 22Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
JAMA. 2021;326(24):2488-2497. doi:10.1001/jama.2021.22002
Key Points

Question  In critically ill adult patients undergoing tracheal intubation, does use of a tracheal tube introducer (“bougie”) increase the incidence of successful intubation on the first attempt, compared with use of an endotracheal tube with stylet?

Findings  In this randomized clinical trial that included 1102 critically ill adults, successful intubation on the first attempt was 80.4% with use of a bougie and 83.0% with use of an endotracheal tube with stylet, a difference that was not statistically significant.

Meaning  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.

Abstract

Importance  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.

Trial Registration  ClinicalTrials.gov Identifier: NCT03928925

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    3 Comments for this article
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    Why Use a Bougie with a Video Laryngoscope ?
    Ramakant Sharma, MD | HonorHealth Shea Health System

    Bougies were designed to assist with mitigating the angle of laryngeal opening with visual axis using direct laryngoscopy.

    With video laryngoscopy, that problem doesn't exist.

    With 75% of trial participants intubated using video laryngoscopy, this trial studied a problem that did not exist.

    CONFLICT OF INTEREST: None Reported
    Limited Experience with Bougie
    Praveen Chahar, MD, FCARCSI | Cleveland Clinic Foundation
    The operators in this trial had limited experience using a bougie as mentioned in the limitations sections. It raises questions about methodology and validity of results as its difficult to compare equipment unless the operators are well versed with that equipment. The lack of superiority of bougie may be related to operator inexperience rather than bougie itself.
    CONFLICT OF INTEREST: None Reported
    Bougie a device that evolved to a new function with videolaryngoscopy
    Marcelo Sperandio Ramos | Anesthesiologist, A. C. Camargo Cancer Center, Brazil
    The tracheal tube introducer (generally nicknamed "bougie") was originally devised as a blind introducer when there was no video laryngoscopy (VL) and the operator had only the epiglottis in view without an actual view of the vocal cords, what would be classified as Cormack 3; or had a restricted view of only the small posterior portion of the glottic aperture (2B). Thus it was indicated for views classified as Cormack 1, 2A, 2B, 3A. If the epiglottis could not be moved and was the only structure to be seen (Cormack 3B) or if even the epiglottis could not be seen (Cormack 4) it is thought to be unhelpful.  Nowadays the function of the introducer (known as bougie, Frova [after the inventor's name], or orange VBM introducer) evolved to a new role as an adjuvant to visual intubation using on-screen VL. Because it is thinner than the endotracheal tube, it occupies less space and is more maneuverable than the tube, making it possible to introduce its tip into the subglottis more easily. In most cases the tube can be maneuvered to the glottis even without the aid of the introducer, but in more difficult cases (eg anterior glottis, the ones that require a hyper angulated blade) the introducer helps, assuming use of a tube with a malleable stylet in the same shape as the VL blade.

    Introducers are sold as straight cylinders (generally about 60 cm long) with an angulated (coudé) tip that performs well whenever you don’t really need them. To get the best aid from this device, especially if you are dealing with a very anteriorly positioned glottis or your patient has a very short thyromental distance, in which you need a hyper angulated blade, you need to manually bend the distal end of the introducer to a “J” shape in order to maneuver its tip toward the glottis, and after crossing the cords turn it 90 – 180 degrees to avoid impact with the cricothyroid membrane and aligning the introducer with the trachea. I usually bend the bougie immediately before its use because the material has a “memory” and the bend tends to disappear in some minutes.

    CONFLICT OF INTEREST: None Reported
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