The BOUGIE Trial
George Kovacs
Clinical Question: Does use of the gum-elastic bougie increase the rate of first-pass endotracheal intubation success when compared to endotracheal tube with stylet in critically ill patients?
Primary Outcome: 1st pass success rate was roughly equal in the two groups (Bougie 80.4% vs Stylet 83.0%)
Discussion
- This study seeks to determine if the findings of the BEAM study (Driver 2018) apply outside of Hennepin County.
- The BEAM trial demonstrated that with routine use, the bougie resulted in improved first-pass success rates.
- It is important to determine if these prior results have external validity.
- In this case, the results of BOUGIE do not support the findings in BEAM.
- Overall first-pass success rate for both approaches was ~ 80% which is relatively poor.
- Interestingly, the first-pass success rate of the endotracheal tube with stylet approach in the BEAM study was about the same as in this study (82%).
- This success rate may be the general rate for the stylet approach.
- At Hennepin county, the low first-pass success rate with stylet may result from the fact that it is not how operators train for intubation (ie, the standard of practice is bougie intubation)
- Emergency intubators should aim for a better first-pass success rate.
- It is important to consider why the results of the BOUGIE trial are so different from the BEAM trial.
- The technique of intubating with a bougie requires deliberate practice in order to be facile with the skill.
- In the Hennepin system, the bougie is standard of practice. As a result, clinicians are adept in its use.
- Overall experience using the bougie in this group was low.
- This study demonstrates that the skill of using the bougie cannot simply be “picked up” and added to the operator's airway approach.
PERSPECTIVE
Bottom Line: In experienced hands, the bougie appears to increase first attempt intubation success rates but, this advantage does not carry over to intubators who do not use the bougie as their standard operating procedure. It’s not about the device; it’s about the skill of the user with that device
Driver BE et al. 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 (BOUGIE Trial). JAMA 2021. PMID: 34879143
Driver BE et al.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.
