Author: Ajai Raj
“[We] didn’t expect quite as significant of a difference as we found,” said Brian Driver, MD, the director of clinical research, Department of Emergency Medicine, Hennepin County Medical Center, in Minneapolis, and first author of the study.
“But I think that’s because in the past we had reserved the bougie for slightly more difficult airways, and this setting we analyzed everyone, including easier airways where we might not have used the bougie before, and really let it shine,” Dr. Driver said.
“I think this study provides a better estimate of the bougie’s success rate when used with all comers.”
The BEAM (Bougie Use in Emergency Airway Management) trial was conducted at Hennepin County Medical Center, an urban, academic emergency department where emergency physicians perform all endotracheal intubations, from September 2016 through August 2017. Researchers randomly assigned 757 patients who were consecutively admitted to the emergency department and underwent initial emergency orotracheal intubation facilitated either by bougie (n=381)—specifically the Macintosh laryngoscope blade (C-MAC [KARL STORZ] and GlideScope Titanium [Verathon])—or endotracheal tube and stylet (n=376). The mean age of the patients was 46 years, and 30% were women.
For the 380 patients with at least one difficult airway characteristic, the rate of first-attempt intubation success was higher in the bougie group than in the endotracheal tube and stylet group (96% vs. 82%; 95% CI, 8%-20%). More surprisingly, the researchers said, the rate of first-attempt intubation success in all patients was higher in the bougie group (98% vs. 87%; 95% CI, 7%-14%). Median duration of first-attempt intubation did not differ significantly between groups, nor did incidence of hypoxemia.
Bougie Use Will Increase in Emergencies
“We had had a suspicion that the bougie would help everyone, just because it makes tube passage so simple,” Dr. Driver said. “We’re in the era now of video laryngoscopy, so getting a good view is much less challenging than it used to be. One of the main causes of failing to intubate on the first attempt is now difficulty in the tube passage, and the bougie makes tube passage much easier.”
This study is likely to result in more frequent use of the bougie in emergency departments and thus “an overall increase in the comfort level of emergency physicians with the use of the bougie,” said John C. Sakles, MD, a professor in the Department of Emergency Medicine at the University of Arizona College of Medicine, in Tucson.
“It is not surprising that the use of the bougie resulted in an increase in first-pass success in patients with difficult airway characteristics,” said Dr. Sakles in an interview, who was not involved with the study. “However, in this study the authors also found that use of the bougie increased the rate of first-pass success in patients with no difficult airway characteristics. While this may seem surprising at first glance, I think it simply represents the fact that it will always be easier to pass a smaller object, such as a bougie, into the trachea than a larger object like a trachea tube.”
Dr. Sakles noted that the lack of a significant difference in either mean duration of first attempt or hypoxemia between the groups provided evidence to refute “one of the common arguments against routine bougie use in the critically ill—that it will take longer and thus may result in more oxygen desaturation. Interestingly, in this study, the time to intubation and prevalence of hypoxemia during intubation were similar with the bougie and the styleted tracheal tube.”
Calling the study “well designed and executed,” Dr. Sakles noted that the findings can only be extrapolated to C-MAC and Macintosh laryngoscope blades used with a “‘naked bougie’ approach, in which the bougie is placed into the trachea and then the endotracheal tube is railroaded over it.” The results cannot be extrapolated to hyperangulated video laryngoscope blades or to the “multitude of ‘preloaded bougie’ techniques in which the bougie is used with a tracheal tube already loaded on it.” He also noted that the study is underpowered to demonstrate the safety of routine bougie use. “It would take a very large number of patients to identify serious, rare complications, such as tracheal or bronchial perforation.”
“We hope this study will encourage people to try the bougie out and to think of it as a primary tool,” Dr. Driver said.