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New Meta-analysis – Should We Do Bougie-First Intubations?

April 5, 2024

Written by Alex Clark

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In this systematic review and meta-analysis to evaluate the use of a bougie versus non-bougie approach (ie. stylet) in intubations of adult patients, a bougie-first approach significantly increased the rate of first-attempt success compared to controls. But what does this say about your intubation strategy?

Allow me to introduce…the bougie!
This well-done systematic review and meta-analysis pooled 18 studies (including 12 RCTs) and a total of 9,151 patients with 4,897 of those in the bougie-first cohort. Most intubations occurred in the out-of-hospital, ED, or ICU setting (n = 8,070 patients, 9 studies). Most studies (61.1%) used DL, the remainder used standard geometry VL. Patient demographics were similar across groups. It is very important to note that the authors declare an overall low certainty for their pooled studies with no studies at low risk of bias.

A bougie-first approach significantly increased the rate of first-attempt success: RR 1.11 (95%CI 1.06 to 1.17), with nearly identical findings in the out-of-hospital, ED, and ICU combined subgroups. This effect was amplified in difficult airways: RR 1.6 (1.4 to 1.84). However, statistical significance was lost in the subgroup of three RCTs involving emergency intubations: RR 1.05 (0.91 to 1.21). Additional pre-planned secondary outcomes suggested there was no increase in hypoxemia, esophageal intubation, or rate of post-procedural cardiac arrest with bougie-first. There was an increase in intubation time with the bougie (~13s increase) and small but greater risk of intubation-related oral injuries.

Overall, the authors suggest that the bougie increases first-attempt success in adult intubations and probably should be used first and NOT as a rescue device. Limitations include low certainty evidence and high risk of bias, high-levels of heterogeneity, no data on operator experience, and a lack of patient-centered outcomes.

How will this change my practice?
I must admit my own bias… I grew up in a home that preached “bougie-left-turn” for every intubation. However, this report is a reminder that airway trials are difficult, and bias is inevitable. The low-level of evidence presented in this meta-analysis just does not yet support the authors’ full recommendation for a bougie-first approach. The bougie remains a powerful instrument, among many other airway adjuncts, in the armamentarium of the emergency physician.

Editor’s note: I thought that since 11 of the 18 studies used DL, this may have made bougie use look better. However, there was still better first-pass success in both DL and VL subgroups. ~Clay Smith

Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2024 Feb;83(2):132-144. doi: 10.1016/j.annemergmed.2023.08.484. Epub 2023 Sep 19.

What are your thoughts?