CRITICAL CARE MEDICINE SECTION
Bougie Conundrum: Airway Adjunct or Secret to 1st Pass Success? Should We Incorporate into Routine Practice and How? Frederick Gmora, DO*, Skyler Lentz, MD FAAEM†, Elias Wan, MD FAAEM‡
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mergency medicine at its purest form is controlled chaos. Apart from the occasional warning of a potential impending disaster, one can never predict who will present next during a hectic clinical shift. The ability to anticipate, strategize, and react rapidly to disasters are essential qualities of the emergency physician or intensivist. Considering emergency airway management, whether it be within the walls of the emergency department or the intensive care unit, there is no exception. The timing of a patient’s last meal, pre-oxygenation status, or mouth full of emesis matters little when they arrive in extremis. Thus, a well-prepared physician will control the chaos by optimizing the conditions to maximize their first pass success rate. Fortunately, for the majority, the number of exceptionally difficult airways or complex anatomy scenarios only comprise a small percentage of the overall cases of intubations. Overall, emergency physicians successfully intubate >99% of patients in three attempts or less, with an 83% first pass success rate.1 While few desire more daunting challenges, the smaller integer does pose a unique challenge for trainees to gain experience and be prepared for the worse. How do they build their armory of adjuncts for the difficult airway?
Figure 1. Equipment preparation. Macintosh blade Video Laryngoscope Handle (top item) and preloaded ETT with bougie (bottom item).
One adjunct often included in emergency airway preparations is the tracheal tube introducer or bougie. It is a commonly described difficult airway adjunct for failed intubation attempts or poor initial laryngoscopic view. The bougie itself is certainly not new, described by Macintosh in 1949, nonetheless, it remains utilized in only a small fraction of intubations.1,2
However, in the last several years there has been a paradigm shift towards utilizing the bougie as the initial attempt device. The shift is in large due to two papers by Driver and colleagues at Hennepin County Medical Center in Minneapolis, Minnesota. The first study, published in 2017, is a retrospective, observational study which showed higher first pass success with the bougie vs. the more conventional stylet and endotracheal tube (ETT) combination when accounting for confounding variables.3 The Bougie Use in Emergency Airway Management (BEAM) trial was published a year later out of the same emergency department.4 This was a randomized control trial comparing first attempt intubation success with the bougie vs. ETT and stylet with those individuals with difficult airway characteristics. Again, there was a significant increase in first pass success in the bougie arm in those with at least one difficult airway predictor (96% vs. 82%) and in the whole study population (98% vs. 87%). Notably, the duration of the first intubation attempt and incidence of hypoxemia was not different between the bougie and stylet groups.4 These two studies though are not without their limitations. Most critical for this discussion is related to their generalizability. They were both conducted at a single center which limits their generalizability. Perhaps more notable for the majority of emergency physicians, located outside this center, was their pre-existing comfort with the bougie as a widely used primary method since 1996. >> COMMON SENSE NOVEMBER/DECEMBER 2021
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