Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation

Driver, Brian E.; Prekker, Matthew E.; Klein, Lauren R.; Reardon, Robert F.; Miner, James R.; Fagerstrom, Erik; Cleghorn, Mitchell; McGill, John W.; Cole, Jon B.

doi:10.1001/jama.2018.6496

Cited by 237 publications

(208 citation statements)

References 46 publications

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“…A recent randomized clinical trial of bougie‐first versus stylet‐in‐tube intubations in ED patients using a standard‐shaped CMAC video laryngoscope revealed improved first‐attempt success when intubators first placed a bougie compared to an ETT loaded with a malleable stylet. These findings suggest that, at least for standard geometry blades, there may be benefit to augmenting VL by bougie use as well …”

Section: Discussionmentioning

confidence: 90%

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Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Brown

Kaji

Fantegrossi

et al. 2020

Academic Emergency Medicine

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Objective The objective was to compare first‐attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A‐DL) with unaided video laryngoscopy (VL) in adult emergency department (ED) intubations. Methods This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A‐DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA‐VL) and standard‐geometry VL (SG‐VL). We report differences in first‐attempt intubation success and peri‐intubation adverse events with cluster‐adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI. Results We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A‐DL or unaided VL on first attempt. A‐DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A‐DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First‐attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A‐DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry‐recorded difficult airway predictors revealed first‐attempt success was higher with all unaided VL compared with any A‐DL (adjusted OR [AOR] = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA‐VL and SG‐VL compared with any A‐DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score–adjusted odds for first‐attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5). Conclusions Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first‐attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.

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Section: Discussionmentioning

confidence: 90%

“…These findings suggest that, at least for standard geometry blades, there may be benefit to augmenting VL by bougie use as well. 22…”

Section: Discussionmentioning

confidence: 99%

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Brown

Kaji

Fantegrossi

et al. 2020

Academic Emergency Medicine

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“…We strongly recommend the use of a videolaryngoscope, which would ideally be disposable but with a separate screen to minimise patient contact. Pre-loading an appropriatelysized tracheal tube on an introducer is also advised, as this may also improve the first-pass success rate [46].…”

Section: Tracheal Intubationmentioning

confidence: 99%

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

et al. 2020

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Summary Novel coronavirus 2019 is a single‐stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non‐technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

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“…Driver et al achieved an FPS rate of 98% with routine use of a bougie in combination with a Macintosh blade VL device. 8 An out-of-package bougie is straight with a coude tip and is meant for Macintosh blade devices. Recognize for some Macintosh VL devices that a slight bend on the distal portion of the bougie may be necessary.…”

Section: What Is the Best Approach To Intubation In Covid-19 Patients?mentioning

confidence: 99%

Just the Facts: Airway management during the coronavirus disease 2019 (COVID-19) pandemic

Kovács

Sowers

Campbell

et al. 2020

CJEM

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CASEA previously healthy 42-year-old male developed a fever and cough shortly after returning to Canada from overseas. Initially, he had mild upper respiratory tract infection symptoms and a cough. He was aware of the coronavirus disease-2019 (COVID-19) and the advisory to self-isolate and did so; however, he developed increasing respiratory distress over several days and called 911. On arrival at the emergency department (ED), his heart rate was 130 beats/min, respiratory rate 32 per/min, and oxygenation saturation 82% on room air. As per emergency medical services (EMS) protocol, they placed him on nasal prongs under a surgical mask at 5 L/min and his oxygen saturation improved to 86%.

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Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation

Abstract: clinicaltrials.gov Identifier: NCT02902146.

Cited by 237 publications

References 46 publications

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Just the Facts: Airway management during the coronavirus disease 2019 (COVID-19) pandemic

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