Bougie 1st Intubation in the ED?

Background: Successful first-pass endotracheal intubation is the desired outcome of all ER physicians as this can stave off hypoxemia and aspiration.  The bougie is one tool we have in our armamentarium that may be able to help with intubation. Many providers use this device as a rescue device after a failed attempt at intubation, instead of as a primary device in intubation.  This study sought to investigate the use of the bougie as a primary intubation device (Bougie 1st Intubation) in the ED instead of as a backup or adjunct in the ED.

What They Did:

• Retrospective, observational study
• Determine the association between bougie use and first-pass intubation success

Outcomes:

• Primary: 1^st Pass Success (defined as successful intubation with a single laryngoscope blade insertion)

Inclusion:

• Adults > 17 years of age undergoing intubation in the ED
• Use of a C-MAC with a Macintosh-shaped blade

Exclusion:

• Missing videos
• Intubated before arrival to the ED
• Patients intubated with hyperangulated laryngoscope blades (i.e. Glidescope)

Results:

• Intubation Stats:
  • C-MAC (Macintosh blade) used in 543 out of 593 intubations (91.6% of cases)
    • More VL used with bougie than without bougie: 46% vs 19%
  • Bougie used in 435 (80%) of cases
• First-Pass Success
  • With Bougie: 414/435 (95%)
  • Without Bougie: 93/108 (86%)
  • Absolute Difference 9%
  • 95% CI 2 – 16%
• Median First-Attempt Duration
  • With Bougie: 40 sec
  • Without Bougie: 27 sec
  • Absolute Difference: 14 sec
  • 95% CI 11 – 16 sec
• Use of bougie independently associated with greater first-pass success = aOR 3.40 (95% CI 1.52 – 7.60)
• Use of the video laryngoscopy device was also independently associated with greater first-pass success = aOR 5.04 (95% CI 1.91 – 13.35)

Strengths:

• Automated software combined video camera footage with, the patients vital signs, as well as audio recordings of the room for more accurate evaluation of endpoints
• First pass success was discretely defined
• This study asks a clinically important question
• Missing data was left blank with no assumed value which would neither over- or under represent endpoints
• 10% of videos were evaluated by a second reviewer to ensure interobserver agreement
• Reviewers were blinded to study aims
• Adjusted for variables that could confound the relationship between bougie use and intubation success

Limitations:

• Single institution with frequent bougie use and familiarity with the device may limit generalizability to other institutions
• Retrospective design subject to bias
• Pre-intubation assessments (ie. Mallampati) were not collected. These can influence first-pass success
• Hypoxemia data could not be obtained from 181 videos (21% of cases), as median duration of intubation was longer with the use of bougie, this would be an important adverse outcome that would need to be monitored
• Adverse events such as upper airway trauma, tracheobronchial injury, or pneumothorax were not recorded in this study

Discussion:

• It would have been nice to see if bougie makes a difference on all airways, simple airways, or more difficult airways where visualization is limited
• Also it is important to remember that a rescue device is only useful if you are comfortable with it, so using it in frequent intubations makes sense, however it is unclear that using it in every intubation is necessary

Author Conclusion: “Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.”

Clinical Take Home Point: This is the largest trial to date on the use of bougie 1^st intubation and first-pass success. However, this study will not change my practice of using a bougie on every intubation.  Further prospective, multicenter RCTs taking into account the costs, adverse events, and pre-intubation assessment of airway difficulty are still needed before changing global practice

References:

1. Driver, B et al. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017. PMID: 28601269

For More Thoughts on This Topic Checkout:

• Terron Trott at 5 Minute Airway: Bougie and the First Pass Success with Interview by Brian Driver (Lead Author)

Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami)