Written by Rebecca White
Spoon Feed
First-pass intubation success rate in ICU patients was higher when a stylet was used versus endotracheal tube alone. Rates of complications were similar between the two groups.
Why does this matter?
It is routine practice to use a stylet with an endotracheal tube (ETT) during intubation via direct laryngoscopy, given the advantages of pre-shaping and directing your tube that are not present when using a tube alone. However, there have been reported complications of stylet use, such as perforation of the trachea or esophagus. If there is no difference in intubation success, why risk this complication?
Intubating in STYLETO
This RCT included 999 patients in 32 ICUs across France. Patients were assigned to either ETT plus stylet or ETT alone for initial intubation attempt using direct laryngoscopy.
First-pass success was significantly better in patients intubated with ETT plus stylet (78.2%) versus ETT alone (71.5%) (risk difference 6.7, 95%CI 1.4-12.1; NNT=15; RR 1.10. 95%CI 1.02-1.18). Rates of complications (traumatic injuries or esophageal intubation) were similar between groups (38.7% vs. 40.2%), as were rates of serious adverse events like severe hypoxemia or cardiac arrest (4.0% and 3.6%).
The SYLETO Trial is the first RCT to compare rates of first-pass intubation success with stylet use versus tube alone in critically ill adults. I’d like to see this study repeated on an emergency department population, though given the similarly difficult physiologic circumstances in ICU patients, results would likely be comparable. In my practice, I’ll continue to reach for a stylet-ed ETT (or a bougie, especially if the patient demonstrates characteristics of a difficult airway).
Source
Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med. 2021 Jun;47(6):653-664. doi: 10.1007/s00134-021-06417-y. Epub 2021 May 25.
Complication rate seems incredibly high, and first pass success rate shockingly low. This doesn’t seem to represent acceptable practice risk of ICU intubation.
Agree.
Interestingly, in the MACMAN RCT, rates were similarly low in critically ill patients. See https://journalfeed.org/article-a-day/2017/macman-poor-first-pass-success.
But I agree, recent ED-based studies have seen first-pass success rates soar to almost 95% with an airway safety bundle. See https://journalfeed.org/article-a-day/2020/a-simple-way-to-improve-first-pass-success.