REBEL Cast Ep107: The BOUGIE Trial – Bougie First in All Emergency Intubations?

Background: Emergency endotracheal intubation is a potentially life-saving procedure in the management of critically-ill patients. The inherent risks associated with the procedure challenge us to refine our skills and adopt new techniques that can improve our performance. The bougie is an inexpensive device that has gained considerable traction in the last ten years. In 2018, a single center study published out of Hennepin County demonstrated that use of the bougie resulted in a massive benefit in terms of first attempt success (Driver 2018). These remarkable results convinced many to adopt the bougie as standard operating procedure (SOP) for all intubations. However, one weakness of the study was that it was performed in a single center where there was a high level of familiarity and skill with the device. Whether the substantial benefits of bougie facilitated intubation extrapolate to other airway operators outside of this system is a topic for debate.

REBEL Cast Ep107: The BOUGIE Trial – Bougie First in All Emergency Intubations?

Article: 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 [Access on Read by QxMD HERE]

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?

Population: Patients > 18 years of age recruited at 15 sites (7 EDs, 8 ICUs) who were undergoing tracheal intubation with a nonhyperangulated laryngoscope blade. 

Outcomes: 

• Primary: Successful first attempt intubation (defined as a single insertion of a laryngoscope blade into the mouth and either a single insertion of a bougie followed by an endotracheal tube or a single insertion of an endotracheal tube with a stylet.)
• Secondary: Incidence of severe hypoxemia (O2 sat < 80%)

Intervention: Intubation with a bougie

Control: Intubation with an endotracheal tube with stylet

Design: Multicenter, randomized, unblinded clinical trial

Excluded: Patients who were pregnant, incarcerated, immediate need for intubation without time for randomization or if the clinician determined that a bougie or a endotracheal stylet was either required or contraindicated.

Primary Results

• • 1558 patients were screened
  • 1102 patients were enrolled and included for primary analysis
    • Median age: 58 years
    • Most common reasons for intubation: AMS (44.6%), Acute respiratory failure (31.5%)
  • 42.0% of patients had 1 or more difficult airway characteristics (Obesity, body fluid obscuring the glottis, cervical spine immobilization, and facial trauma)
  • 62.9% of physicians were EM and most operators were resident physicians (61.6). Median number of intubations prior to study was 60 and median of 10 prior intubations using a bougie
  • Video laryngoscope use:
    • Bougie group: 75.7%
    • Stylet group: 73.8%
  • Received intervention randomized to
    • Bougie group: 98.6%
    • Stylet group: 97.3%

Critical Findings:

Strengths:

• Asks an important clinical question
• Broad inclusion criteria with minimal exclusion criteria increasing applicability of results.
• Baseline characteristics well-balanced between groups.

Limitations:

• Study was unblinded to bougie or stylet which may introduce a bias
  • Did intubators abandon the bougie more readily in their intubation attempts (or vice versa, did they try for a longer period of time with the bougie?)
• Primary outcome (first-pass success) is a surrogate marker for a clinical outcome.
• Study excluded from randomization any patient whom the clinician believed would benefit from a bougie or in whom there was a contraindication (only a small number of patients were excluded for this reason). Excluding those who would be more likely to benefit may bias these results towards the null hypothesis.

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 result in improved first-pass success rates.
  • 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 stylet in the BEAM study was about the same as in this study (82%).
    • This success rate may be the general rate for endotracheal tube stylet.
    • 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 SOP is bougie intubation)
  • Emergency intubators should shoot for a better first-pass success rate which appears to be bougie but with increased training on this modality.
• 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 SOP. As a result, clinicians are adept with bougie use.
  • Overall level of experience with the bougie was low (median of 10 intubations with the device).
  • This study demonstrates that the bougie cannot simply be picked up and added to the operator’s airway approach.
  • The bougie isn’t magic; it’s about the skill of the user.

Authors Conclusions: 

“Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.”

Our Conclusions: In this multicenter, randomized trial, the bougie did not have a better first attempt success rate than an endotracheal tube with stylet in critically ill patients.

Potential to Impact Current Practice: The results of this study call into question the significant improvements seen with bougie use in the BEAM trial.

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.

For More on This Topic Checkout:

• First10EM: The BOUGIE Trial: No difference between bougie and stylet?
• REBEL EM: Bougie use in Emergency Airway Management (BEAM)

References:

1. 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. PMID: 29800096