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
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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Professor
Nassau University Medical Center
No conflicts of interest (coi).
- EMCrit 389 – Massive Transfusion Update and Hemostatic Resuscitation - December 1, 2024
- EMCrit 388 – Experts' Guide to the Bougie with Barnicle and Driver - November 22, 2024
- EMCrit RACC Lit Review – October/November 2024 - November 7, 2024
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?