Written by Aaron Lacy
In this large ED and ICU multicenter RCT there was no difference in first pass success rate in intubations done with bougie first or ETT + stylet attempt.
Why does this matter?
First pass success matters in intubation, as subsequent intubation attempts are associated with worse patient outcomes. VL has been revolutionary in improving first pass success rate, but what else can we do to improve? The BEAM trial showed substantially improved first pass success when bougie was used as a primary tube introducer, but this was a single center study. If this holds up in a multicenter RCT, it would be practice changing for all providers.
Is it bougie to use a bougie?
This multicenter ED and ICU randomized control trial looked at first pass success rate; patients were randomized to either bougie first (n=566) or ETT + stylet (n = 546) when undergoing RSI. There was no difference between bougie (80.4%) and ETT + stylet (83.0%) in first pass success rate (95% CI, [-7.3 – 2.2], p=.27). A secondary outcome showed no difference in severe hypoxemia (<80%) between bougie (11.0%) and ETT + stylet (8.8%) (95% CI [-1.6 – 6.0]). This trial had a large mix of providers between residents (61.6%) and attendings in the ED (62.9%) and ICU. Of note, when looking at subgroup analysis there was no statistical difference between bougie and ETT + stylet when looking at provider, location, or patient characteristics.
How can one RCT show massive improvement but when expanded show no difference at all? It could come from the fact that the BOUGIE trial had more unique (only 1 intubation enrolled in the study) operators. In general, the enrolling sites reported that they rarely or only sometimes used the bougie in their general care, meaning they had less experience and time to learn proper bougie use. I am a big fan of bougie first, as it keeps me facile with its use. And you never know when you will encounter a difficult airway. For now, it seems whatever camp you fall into is safe.
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 8. doi: 10.1001/jama.2021.22002. Epub ahead of print.