Historically, the bougie has been known as a backup airway device once standard approaches to airway access fail. In the last three years, the bougie has gained more attention, largely through two trials performed at Hennepin County previously discussed HERE. The first showed an association with increased first pass success performed in a retrospective review of intubations performed in the emergency department. The second was a landmark study showing when randomized to bougie versus ETT and stylet in cases with expected difficult airway, first pass success was dramatically improved. However, these amazing findings have yet to be reproduced outside of Hennepin County Emergency Department.
While a multi-center, pragmatic, randomized trial is underway in ICU patients, we now have more evidence that bougie improves first pass success from a pre-hospital EMS system in Seattle, Washington:
What they did:
- This was a prospective, observational study of a pre- and post- policy change to implement the bougie as the initial method to intubate.
- Intubation was performed by ground paramedics with a minimum of 10 intubations per year.
- All intubations were performed with direct (Macintosh) laryngoscopy using RSI – no video was available.
- The ‘control period’ was defined as 18-months prior to policy change. There was a 3 month ‘training’ period, followed by another 18-month ‘bougie period’.
- 40.7% and 49% of intubations pre- and post- policy change respectively, were during cardiac arrest.
- 823 patients fell into the pre-intervention period.
- 70% overall first pass success.
- 8.9% patients were intubated with the bougie prior to policy change.
- 771 patients intubated in the post-intervention period.
- 77% overall first pass success
- 81.3% patients intubated with the bougie after policy change.
FIRST PASS SUCCESS BY CORMACK LEHANE AIRWAY GRADE
Grade 1 View
Grade 2 View
Grade 3 View
Grade 4 View
*denotes significant value
This study is the first prehospital analysis of a bougie-first strategy for intubation. The patient population has many inherent challenges – intubation may be performed in the field or in the back of the ambulance and many of the patients were receiving CPR. None of these features make for an easy intubation – which is a great opportunity for the bougie to shine. While our observed FPS isn’t as high as the BEAM trial, it is likely due to the stated challenges. Importantly, we again see the bougie performs well as the airway view becomes worse and intubation becomes more challenging. The grade 3 intubation success nearly doubled when using the bougie, a reassuring finding when you’re the operator and all you see is epiglottis. Overall, this study confirms the findings of Hennepin County and adds to the picture that bougie should become part of routine intubation.
There are some limitations to this study. The pre-post methodology has an inherent risk of bias compared to a true randomized study; ongoing training and improvement in provider skill can’t be controlled for. Crossover events were a substantial portion of the bougie period (18.7%) and we’ll be unable to determine whether the magnitude of effect would have changed had all intubations been performed with the bougie. We also can not apply these findings to systems using video laryngoscopy or other intubation methods.
Comments from the Airway and Vent Team at Critical Care Now:
- Terren Trott: I personally am a huge advocate for the bougie and use it for all Mac or Miller intubations. I push my residents to become familiar with it prior to ‘needing’ it because there are some nuances to manipulation and requires a slightly more delicate approach.
- Matt Suiba: The combination of the Driver studies as well as this pre-hospital observational study supports, at minimum, that first-attempt use of the bougie is safe and probably beneficial for the endpoint of first pass success. In my experience, it’s easier to maintain view of the glottis and surrounding structures since it’s a smaller caliber (Image 1), and seems to improve success in grade 2 & 3 views in particular. Like Terren, I try to get trainees comfortable with its use in “routine” cases so that they will feel comfortable reaching for it in difficult airway circumstances. A couple caveats:
- I generally advocate for the bougie when standard geometry laryngoscopy is used (video or not), because hyperangulated view adds a layer of complexity. It requires extra manipulation of the bougie beforehand which may diminish the potential benefits.
- Secondly, I teach (and personally use) the Kiwi grip because it provides superior dexterity and does not require a second operator to be involved to feed the tube, etc.
- Steve Haywood – “Hope for the best, plan for the worst:” Despite all of my attempts to evaluate for an anatomic difficult airway, I still find unanticipated difficult airways. The first attempt will likely be the best attempt so I am also a proponent of a bougie first approach. If it is an easy airway, there is no harm caused by going bougie first. If I do not start with the bougie and I must abort my first attempt because the bougie is not ready, time is lost and the possibility of creating airway trauma has increased. However, training with the device is important. The proceduralist must know how to set up the bougie (Kiwi grip) and understand how to manipulate the coudé tip. Practice with a mannequin can quickly develop these skills.
Image 1. The smaller caliber of the bougie leads to an improved view of the vocal cords. Image by Dr. Richie Cunningham. Original post HERE..
- This was a single-site, pre-post intervention study where bougie became the initial method of intubation compared to ETT and stylet.
- This study confirms prior studies that have shown higher first pass success when using a bougie-first method.
- This study also gives insight into the utility of the bougie during cardiac arrest, an inherently difficult intubation scenario which represented nearly half the patient population.
- Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med. 2017 Oct;70(4):473-478.e1. doi: 10.1016/j.annemergmed.2017.04.033. PMID: 28601269.l
- Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. PMID: 29800096; PMCID: PMC6134434.
- Latimer AJ, Harrington B, Counts CR, Ruark K, Maynard C, Watase T, Sayre MR. Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting. Ann Emerg Med. 2021 Mar;77(3):296-304. doi: 10.1016/j.annemergmed.2020.10.016. Epub 2020 Dec 17. PMID: 33342596.