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?

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.