Study finds similar success rates with two devices for breathing tube placement


by Leigh MacMillan

Two devices for placing a breathing tube during critical illness had similar success rates for intubation on the first attempt, according to a study published Dec. 8 in JAMA.

A randomized, multicenter clinical trial compared the use of a tracheal tube introducer (“bougie”) with an endotracheal tube with stylet to intubate critically ill patients.
Matthew Semler, MD

“More than 2 million critically ill adults experience intubation each year, and the procedure has a high risk of complications despite taking only two minutes to complete,” said Matthew Semler, MD, assistant professor of Medicine and co-first author of the JAMA study.

Up to 20% of intubations in emergency departments (EDs) or intensive care units (ICUs) require more than one attempt, and multiple attempts are associated with an increased risk of severe hypoxemia (low blood oxygen), cardiac arrest and death.

Historically, most emergency intubations in the U.S. have been performed by inserting a stylet, a malleable metal rod, into an endotracheal tube which is then placed in the trachea. An alternative approach uses a bougie, a long, thin plastic rod that can be placed into the trachea allowing insertion of the endotracheal tube over the bougie. This approach has traditionally been reserved for difficult intubations, but despite limited studies comparing the two, experts have recently encouraged routine use of a bougie during every intubation.

The BOUGIE trial randomized 1,102 critically ill patients to intubation using a bougie or endotracheal tube with stylet at 11 U.S. hospitals (seven EDs and eight ICUs) between April 29, 2019 and Feb. 14, 2021. The trial was led by investigators at Vanderbilt University Medical Center and Hennepin County Medical Center in Minneapolis, Minnesota.

The investigators found that successful intubation on the first attempt occurred in 80.4% of patients in the bougie group and 83.0% of patients in the stylet group, which was not a significant difference between the two approaches.
Jonathan Casey, MD

“Some providers will be surprised as these results are contrary to the finding of a prior small single-center study and the predictions of many experts,” said Jonathan Casey, MD, assistant professor of Medicine and co-senior author of the JAMA study.

Rates of complications such as severe hypoxemia, esophageal intubation, pneumothorax (air between lungs and chest wall), and injuries to oral, larynx or chest structures, were also similar between the two groups.

The trial excluded patients who required urgent intubation and could not be randomized, so the results may not apply under specific circumstances, such as cardiac arrest, the authors noted. Patients who were being intubated with a hyperangulated laryngoscope or those known to have abnormal airway anatomy requiring use of a bougie were also excluded from the trial.

In future studies, the investigators will continue to work to improve the safety of this emergency procedure by comparing different types of laryngoscopes, different devices for providing oxygen, and the most common medications for the procedure.

VUMC authors in addition to Semler and Casey include Janna Landsperger, PA-C, Karen Jackson, MD, and Todd Rice, MD, in the Division of Allergy, Pulmonary and Critical Care Medicine; Wesley Self, MD, and Kevin High, RN, in the Department of Emergency Medicine; Christopher Hughes, MD, and Bret Alvis, MD, in the Department of Anesthesiology; and Li Wang, MS, and Christopher Lindsell, PhD, in the Department of Biostatistics.