We recently published an expert review on the use of a bougie for EM airway management. Today, we discuss the paper and a ton of other stuff regarding bougie use…
The Guests
The Paper
Managing Emergency Endotracheal Intubation Utilizing a Bougie
by Ryan N. Barnicle MD, MSEd, Alexander Bracey MD and Scott D. Weingart MD
Discussion
Now at the end of 2024, is there enough evidence to support a bougie-first approach for emergency endotracheal intubations?
- Driver et al 2018 (BEAM Trial – JAMA) – Yes – for expert users
- Driver et al 2021 (Bougie Trial – JAMA) – Equivalent for novice users
- Von Hellman et al 2024 (SAMA – Annals) – Yes
Why then is there not universal uptake? And why do operators continue to struggle with the bougie?
Which Bougie?
Single use
Brand: Frova probably best of the “blue bougies” – but we did not commit to this in paper. SunMed also makes a totally utile bougie
Length: 70cm > 50 cm
Depth marker: Barnicle can make a case for this, Scott and Brian don't care
Preloading?
Nope!!!
Narrow Diameter compared to stylet-over-ett
- Swelling, soiling,
Grade III / IV – emphasize that this is certainly where bougie shines but is still difficult and practice in better views lends itself to success here
Pre-Curving / Snail Tail:
Ryan and Scott prefer, Brian starts straight
Rotation
Maybe for the bougie; definitely for the tube!!
Confirmation
Tactile Feedback
- Clicks: meh
- Hold up sign: reliable, but not necessary to seek out if you see it going through
Steerable Tip Bougie
Can you use bougie for HAVL?
A: Probably shouldn’t yet unless specialized bougie.
- 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. 2024 Jun;79(6):603-610. doi: 10.1111/anae.16202. Epub 2023 Dec 19. PMID: 38114306.
Foundational Technique
Stabilizing w/ one hand if solo
Additional New Information
- Comparison of different bougies [DOI: 10.1111/anae.15624]
More on EMCrit
- EMCrit 299 – Bougie Masterclass with George Kovacs
- EMCrit Guest Post – Bougie Lessons from the Literature and Experience by George Kovacs
- EMCrit Guest Post – Drawing Circles for Bougie Hangup by Neil Dasgupta
- EMCrit 226 – Airway Update – Bougie and Positioning
- EMCrit Wee – Bougie Prepass and CricCon for Difficult Airway
- Bougie Stuff
Additional Resources
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- EMCrit RACC-Lit – January 2025 - February 4, 2025
- EMCrit 393 – CV-EMCrit – Inotrope Basics Part 1 - January 25, 2025
- EMCrit Wee (392.5) – Naughty or Nice? Bad Behavior in Healthcare with Liz Crowe, PhD - January 15, 2025
One of my teachers uses this technique:
Advantages: faster, no problems with getting stuck etc. in easy intubations.
What are your thoughts on this technique?
This is super helpful for me. I am in a Level 3 facility CCU/MICU/SICU unit. I would love to know are there any video tutorial where you narrate as you navigate complications or trouble spots with tips to proceed with success?
I use a bougie for every critical care intubation. One key advantage is that it removes a decision point in the process – I don’t have to make a call on how good the view is and whether I should try with just the tube. This saves time, and the assistant / whole team know that whatever the view on the screen, we’re going first pass with the bougie. Totally agree that using it for the easy ones trains your skills and makes you comfortable when a harder one comes along. But it also trains the assistants in the routine,… Read more »
Hi! Absolutely loved the post and the podcast, since hearing Scott for several years I’ve been a huge advocate for the use of bougie in all ED or ICU int ubations. I can’t seem to be able to read the full article on Annals, hope I will soon, thank you.
Coude is French (for elbow) to my understanding. The e is not pronounced as it is coude not coudé. Should be pronounced……
https://youtu.be/ezEz4rHBRog?si=f28sBYKwj8B2ggt1
In the US it is always pronounced with and usually written with the accent over the terminal ‘e’
for instance, see:
https://sedationresource.com/sunmed-bougie-endotracheal-introducer-with-coude-tip-adult/