SGEM#271: Bougie Wonderland for First Pass Success

Date: October 17th, 2019 Reference: Driver 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 May 2018 Guest Skeptic: Missy Carter, former City of Bremerton Firefighter/Paramedic, currently a physician assistant practicing in emergency medicine in the Seattle area and an adjunct faculty member with the Tacoma Community College paramedic program. Case: You are preparing for a rapid sequence intubation in a patient suffering from respiratory distress. While doing your airway assessment you notice some difficult airway characteristics (obese patient with a small mouth opening). In the past you’ve had failed first pasts attempts on a similar patient and used a bougie as your back up device. You wonder if this time you would be more successful using the bougie for your first attempt. Background: We have covered airway a number of times on the SGEM. This has included supraglottic airways for OHCA (SGEM#247), POCUS for confirming endotracheal tube placement (SGEM#249) and non-invasive positive pressure ventilation for OCHA (SGEM#96) just to name a few. However, we have never covered the issue of using a bougie for intubation.  For many years the bougie has been considered a back up or “rescue” airway tool and only pulled out after one or even several failed intubation attempts. Many studies have shown that multiple intubation attempts can increase mortality and morbidity, so we are always striving to increase our first pass intubation success rates to improve patient care. Clinical Question: Does using a bougie increase first pass intubation success? Reference: Driver et al. The Bougie and First-Pass Success in the Emergency Department. Annals of Emergency Medicine 2017 Population: Adult patients (age > 17 years) who underwent intubation in the emergency department Excluded: Patients with missing videos that recorded the intubation, cases in which a bougie was used with a hyper angulated video laryngoscope blade (GlideScope) or were intubated before arrival to the emergency department Intervention: Bougie with Macintosh or CMAC laryngoscope Comparison: Intubation with endotracheal tube and stylet Outcome: Primary Outcome: First-pass success rates Secondary: Duration of attempts, hypoxia and esophageal intubations Authors’ Conclusions: “Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Yes Was the follow up of subjects complete enough? Yes How precise are the results? Fairly precise given the small sample size Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Key Results: There were 543 patients included in this cohort. The median age was in the late 40’s and more than two-thirds were male. The vast majority (~95%) of the intubations were performed by a senior resident. First-pass success was greater with than without bougie Primary Outcome: First-pass success 95% with bougie vs. 86% without bougie Absolute difference 9% (95% CI; 2% to 16%) Secondary Outcomes:  Median first-attempt duration was higher with than without bougie (40 seconds vs. 27 seconds) with a difference of 13 seconds (95% CI; 11 to 16). Hypoxia 17% with and 13% without bougie