An Ode to Bougie
Written by Paul Johnston
So what’s a bougie? If you already know, skip this paragraph. A bougie is a flexible rod used to aid intubations. During a “conventional” intubation an ET tube with a malleable metal stylet inside is pushed past the vocal cords into the airway, then the stylet is removed, the cuff inflated, voila. Since a bougie is smaller than an ET tube (~half the diameter of a 7.5 ET tube), in theory it is easier to push past the cords. Once the bougie is in place, an ET tube (with no stylet) is railroaded over the tube into place, the cuff is inflated, and the bougie is removed. Boom.
The BEAM Trial
The 2018 BEAM trial found that first-pass success with what that study defined as a “difficult” airway with VL/bougie was superior to VL/conventional (96% vs 82%). BEAM was an RCT that enrolled 757 ED patients, but all were at a single site. Many in EM concluded VL/bougie > VL/conventional, and in fact this writer’s first ever intubation was a (COVID) VL/bougie that worked out as advertised.
The BOUGIE Trial
Hot off the presses is the BOUGIE trial, just published last week in JAMA. The BOUGIE trial was a multi-center RCT comparing conventional and bougie intubations of “critical” patients in ICUs and EDs. Both VL and DL were permitted. The trial showed there was no statistically significant difference between the two. But let’s take a deeper dive into how this study was performed and how some factors may or may not be relevant to our practice in the ED:
1) 62.9% of those performing intubation in the study were EM physicians, but the remainder were ICU physicians
2) 61.6% were residents
3) Of the 1477 subjects who met inclusion criteria, 282 (~19%!) were excluded due to requiring intubation “too urgently” to be randomized.
So which study is “right”? On the one hand, BEAM was 100% ED intubations while BOUGIE was ~1/3 non-ED intubations. On the other hand, BOUGIE was larger and multi-site and allowed for both VL or DL. On the 3rd hand, we can’t know how the ~19% of “too urgent” patients who were excluded could have impacted the data, but this writer’s intuition is the excluded 19% is a fairly important cohort for ED physicians to consider.
Bad & Bougie
Not related to intubations but heavily featuring bougies: did you know that four members of our residency won the 2021 EMRA Quiz Show trivia contest? Team name Bad & Bougie. Here’s an exclusive pic of the team at East Harlem Bottling Company celebrating their victory at a TNF in the Spring.
None! Read the data for yourself, talk to an attending, and make up your own mind. What may be worth considering is this: do some bougie intubations so that you get comfortable with using this tool. Don’t wait for a difficult airway to present itself that you feel “needs a bougie” and then attempt to deploy it for the first time. A device that we aren’t comfortable using probably isn’t the best thing to expect to be a “rescue device.”
Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. 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 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. PMID: 29800096; PMCID: PMC6134434.
Driver BE, Semler MW, Self WH, 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. Published online December 08, 2021. doi:10.1001/jama.2021.22002