A 68-year-old man presents to the emergency department (ED) with altered mental status and fever. Vital signs on arrival are:

• Temperature: 38.8 degrees Celsius
• Heart rate:128
• Blood pressure: 74 over 48
• Respiratory rate: 10
• Oxygen saturation: 77 percent

Physical examination was notable for lethargy and confusion. He has an absent gag reflex. He has a Class I Mallampati view and lung sounds were diminished in all fields.

Image of a bougie device courtesy of Dr. David Effron.

How Should His Airway Be Managed?

A study in the February issue of Annals conducted a meta-analysis of 18 studies and concluded that bougie use was associated with increased first-attempt intubation success.¹ The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane grade III or IV (only epiglottis seen or neither glottis or epiglottis seen on direct laryngoscopy). The authors conclude, “despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device.”

Is the Evidence from This Research Sufficient to Change Practice?

Some important limitations of this analysis should be recognized. The 18 studies represent a diverse group of patients and study design; 12 of the studies were randomized controlled trials. There was no analysis of operator experience or expertise. Only 60 percent of subjects underwent direct laryngoscopy, the only technique to which the Cormack-Lehane CL) classification technically applies. The study found a mean increase in time to intubation of 13 seconds in the ED setting. Finally, the authors note that intubation-related injuries may be more common in those intubated with a bougie. These limitations are sufficient to question the recommendation to use a bougie as first line airway management.

For patients requiring emergency airway management, the use of a bougie is an important technique. Previous studies have demonstrated the success rate of using a bougie; however, there are conflicting reports about its success as a first pass technique. Most patients (95 percent) have a CL grade 1 or 2a view, and will likely be a successful first pass intubation.² A study published in JAMA in 2018 found that among patients with a difficult airway characteristic, bougie use resulted in higher first attempt intubation success (96 percent), compared to endotracheal tube with stylet (82 percent).³ Other studies have found that bougie use does not improve first attempt success rate.^4,5 A recent study found that among 1102 critically ill adults, successful intubation on the first attempt was 80.4 percent with use of a bougie and 83.0 percent with use of an endotracheal tube with stylet, a difference that was not statistically significant.⁶ A study found that if a difficult airway is anticipated and a hyperangulated video laryngoscope is used, the first attempt success rate is higher when a bougie is used, compared with stylet.⁷ How then do we interpret these conflicting reports in the literature?