Background: In 2018, the BEAM Trial, a small single-center randomized clinical trial, conducted in the emergency department at Hennepin County Medical Center, demonstrated that bougie use significantly increased the first-attempt intubation success rate compared to the endotracheal tube with stylet (98% vs 87% (absolute difference, 11% [95% CI, 7% to 14%]).¹ Conversely, the 2021 BOUGIE trial—a larger, multicenter randomized clinical trial conducted by the same investigators—found no significant difference in first-attempt intubation success between the bougie and an endotracheal tube with stylet among critically ill adults.² Moreover, the American Society of Anesthesiologists’ 2022 Practice Guidelines for Management of the Difficult Airway recommend the use of adjuncts like bougies in anticipated difficult airways but stop short of endorsing their routine universal use.³The question of whether bougies should be used as the primary approach for all intubations remains unresolved. The systematic review and meta-analysis covered here aims to provide clarity by pooling clinical trial data to obtain a single point estimate.

Paper: von Hellmann R, Fuhr N, Maia IWA, et al. Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systemic Review and Meta-Analysis. Ann Emerg Med. 2024 Feb 83(2):132-144. PMID: 37725023

Clinical Question: In adult patients requiring tracheal intubation, does the use of a bougie compared to a stylet improve the first-attempt success rate?

What they did:

The authors performed a systematic review and meta-analysis utilizing the PRISMA guidelines.
A medical librarian with expertise in systematic reviews, searched Cochrane, Embase, Medline, Scopus, and Web of Science for relevant randomized controlled trials and comparative observational studies from inception to June 2023.
Included patients from out-of-hospital, emergency department, intensive care unit, and operating-room intubations.
Researchers used the Cochrane Risk of Bias Tool to assess bias in randomized controlled trials, and observational studies were assessed with the modified Newcastle-Ottawa scale.
The Grade methodology was utilized to asses the level of certainty.
Registered at PROSPERO (CRD42023403212)

Population:

Inclusion criteria:

Adult intubation using a bougie as an intervention compared to usual care (intubation with or without a stylet).
Intubation performed in all settings (out-of-hospital, emergency department, ICU, and operating room).
Studies that report the outcome of first-attempt intubation success for both bougie and non-bougie groups.
Randomized controlled trials or comparative non-randomized observational studies.

Exclusion criteria:

Manikin and cadaver studies.
Studies using only hyper-angulated video laryngoscopy or channeled laryngoscopic devices (e.g., airway scope).
Studies comparing different types of bougies.
Studies published in languages other than English, Portuguese, or Spanish.
Conference abstracts.
Studies lacking a control group or that do not report first-attempt success for both bougie and non-bougie groups.

Intervention: Intubation performed using a bougie..

Comparator: Intubation performed using a standard stylet or no introducer at all.

Outcomes:

Primary Outcome: First-attempt intubation success

The successful placement of the endotracheal tube on the first laryngoscope insertion.

Secondary Outcomes:

First-attempt success without clinically important complications (e.g., hypotension, hypoxemia).
Incidence of hypoxemia, defined as oxygen saturation <90%.
Postintubation arrest.
Duration of intubation.
Incidence of intubation-related injuries, such as airway trauma.
Occurrence of esophageal intubations.
Occurrence of postprocedural sore throat.

Results:

Article selection:

3915 studies identified.
- 1217 duplicated removed.
2699 studies screened for review.
- 2565 studies excluded after reviewing titles and abstracts.
134 full-text articles were assessed for eligibility.
- 116 studies excluded based on eligibility criteria.
18 studies were included:
- 12 randomized controlled trials
- 6 observational studies
The papers included a total of 9151 intubated patients.

Primary outcome: First-attempt intubation su...

Threading the Needle: Bougie-First Intubation

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