Use of a bougie has several important advantages, including improved visibility compared to ETT without bougie, and tactile confirmation of endotracheal placement.⁷ However, the bougie should not be used as a substitute for proper laryngoscopy technique.

As with any procedural device, operator expertise is an important component of its successful use. Some argue that bougie should be used routinely to improve success rate. Others argue that routine use may subject patients to unnecessary airway trauma or intubation delays. Ultimately, the existing literature does not yet provide a clear resolution to this question.

Case Resolution

For this case, endotracheal intubation is indicated. In the setting of normal anatomy with Mallampati Class I view, intubation with video laryngoscopy is appropriate. If the Cormack-Lehane classification is unexpectedly III or IV, the use of a bougie may be appropriate to facilitate endotracheal intubation. Having a bougie readily available with the usual airway equipment may expedite airway management.

Disclaimer

This is not an exhaustive review of airway management, but a commentary on a recent article published in Annals of Emergency Medicine. Readers should consult authoritative sources for in depth recommendations for airway management.

Dr. Marco is professor of emergency medicine at Penn State Health-Milton S. Hershey Medical Center and associate editor of ACEP Now.

References

1. von Hellmann R, Fuhr N, et al. Effect of bougie use on first-attempt success in tracheal intubations: a systematic review and meta-analysis. Ann Emerg Med.2024;83(2):132-144.
2. Koh LK, Kong CE, et al. The modified Cormack-Lehane score for the grading of direct laryngoscopy: evaluation in the Asian population. Anaesth Intensive Care. 2002;30(1):48-51.
3. Driver BE, Prekker ME, 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;319(21):2179-89.
4. Waldron O, Sena R, et al. Using a bougie with C-MAC video laryngoscopy did not improve first-attempt intubation success rates in critical care air transport. Air Med J. 2023;42(6):445-9.
5. Brown CA 3rd, Bair AE, et al. Techniques, success, and adverse events of emergency department adult intubations [published correction appears in Ann Emerg Med. 2017 May;69(5):540]. Ann Emerg Med. 2015;65(4):363-370.e1.
6. Driver BE, Semler MW, 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. JAMA. 2021;326(24):2488-97.
7. Eum D, Ji YJ, Kim HJ. Comparison of the success rate of tracheal intubation between stylet and bougie with a hyperangulated videolaryngoscope: a randomised controlled trial. Anaesthesia. 2023: online ahead of print. 16202. Published December 19, 2023. Accessed March 26, 2024.
8. Cunningham R: The bougie as an airway savior. ACEP Now. 2021;40(2). Available at: https://www.acepnow.com/article/the-bougie-as-an-airway-savior/?singlepage=1. Accessed March 26, 2024.