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
Driver BE, Semler MW, Self WH, et al. JAMA. 2021;326(24):2488-2497.
In 2018, the Bougie use in Emergency Airway Management (BEAM) trial showed a first-pass success rate of 96% with a bougie vs 82% with an endotracheal tube with stylet in an unblinded single-center study.
The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, parallel-group, unblinded, randomized trial from 15 sites across the U.S. enrolling patients receiving rapid sequence intubation and excluding patients who were pregnant, those who needed immediate intubation and could not wait for randomization, and those for whom the provider believed a certain technique would be clearly better or worse.
The primary outcome was first-pass success, defined as a single insertion of a blade into the mouth and a single insertion of the device to which the patient was randomized.
The authors screened 1,558 patients and enrolled 1,106 (71.0%); the median age was 58 years, and 41% were women.
The most common providers were EM physicians (62.9%), most whom were residents (61.6%). Video laryngoscopy was used approximately three-quarters of the time in both groups (not hyperangulated).
First-pass success was observed in 80.4% of the bougie group vs 83% of the stylet group.
The median time to intubation was 124 seconds for the bougie group vs 112 seconds for the stylet group. Hypoxia (O2 saturation <80%) occurred in 11% of the bougie group vs 9% of the stylet group, and serious adverse events or airway complications from the intubation were rare in both groups.
The groups showed essentially comparable results for all outcomes.
Two striking differences in the findings exist between the BOUGIE and BEAM trials. First, the BEAM results strongly favor a bougie, whereas the BOUGIE results show essentially no difference. This difference between studies might have been due to the much broader provider cohort in the BOUGIE trial, including approximately 40% ICU physicians from 15 sites who were less experienced with bougies at the onset and might not have been as invested in their success. Second, in the BOUGIE trial, the first-pass success rates in both groups were relatively low, possibly because the definition of first-pass success was fairly strict. When the authors applied the same definition used in the BEAM trial (one blade insertion, regardless of the number of stylet/bougie insertions), the success rate rose to closer to 90% but still did not show a difference between groups.
Although this is a well-conducted trial, 3 critical questions remain unanswered: (1) Might a difference exist in the hands of more experienced operators (eg, if all highly experienced community physicians had been examined)? (2) Might a difference exist in the most critical cases (eg, cardiac arrest), which were excluded from this trial? (3) Might certain patient-specific characteristics make 1 technique more successful than the other?
EDITOR’S COMMENTARY: In this well-conducted randomized trial focused on emergent airways, contrary to previous evidence, the authors found no difference in first-pass success or other relevant outcomes between using a bougie vs the standard tube loaded over a stylet for endotracheal intubation.
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