From the Guidelines
Using a bougie during intubation is recommended as it significantly improves first-attempt success rates, particularly in difficult airway scenarios, with an increase in success rate of approximately 14% compared to direct laryngoscopy alone, as shown in a large randomised controlled trial 1.
Key Points to Consider
- The use of a bougie increased first-pass success in patients with at least one difficult airway characteristic, with an absolute difference of 14% 1.
- A bougie is superior to a stylet in terms of first pass success rate for both direct and videolaryngoscopy 1.
- Clinicians should consider using an adjunct such as a stylet or bougie when performing tracheal intubation in a patient whose cervical spine is immobilised 1.
Technique and Safety Considerations
- The bougie should be inserted with the curved tip facing anteriorly, advanced until resistance is felt or "tracheal clicks" are detected, then used as a guide for endotracheal tube placement.
- Standard bougies are 60-70 cm long with a 15° curved tip and should be lubricated before use.
- Potential complications include trauma to airway structures if excessive force is used, so gentle technique is essential.
Clinical Decision Making
- The decision to use a bougie should be based on the individual patient's airway characteristics and the clinician's expertise and experience.
- In cases where the laryngeal opening is poorly seen, the use of a bougie or stylet is recommended 1.
From the Research
Benefits of Using a Bougie During Intubation
- The use of a bougie during intubation has been shown to improve first-attempt success rates in patients with difficult airways 2, 3, 4.
- A study published in 2017 found that the overall success rates of intubation using a laryngeal mask airway with a bougie were 92%, compared to 96% using video laryngoscopy 5.
- Another study published in 2024 found that the bougie approach demonstrated a superior first-attempt success rate compared to the stylet approach in patients with difficult airways (93.8% vs. 76.4%) 2.
- A randomized clinical trial published in 2018 found that the use of a bougie resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation (96% vs. 82%) 3.
- A study published in 2011 found that bougie-assisted intubation had a higher success rate than traditional endotracheal intubation in a simulated difficult airway (94% vs. 77%) 6.
- A prospective, observational study published in 2021 found that routine use of a bougie improved first-attempt intubation success in the out-of-hospital setting, with a first-attempt success rate increasing from 70% to 77% 4.
Comparison of Bougie and Stylet Approaches
- A meta-analysis published in 2024 found that the bougie approach did not exhibit superiority in first-attempt success rate or total intubation success rate compared to the stylet approach in all patients 2.
- However, in patients with difficult airways, the bougie approach demonstrated a superior first-attempt success rate compared to the stylet approach 2.
- A study published in 2018 found that the use of a bougie resulted in significantly higher first-attempt intubation success among patients with difficult airways, but the median duration of the first intubation attempt and the incidence of hypoxemia did not differ significantly between the bougie and endotracheal tube + stylet groups 3.
Ease of Intubation and Complications
- A study published in 2011 found that participants perceived bougie-assisted intubation as being easier to perform than traditional endotracheal intubation in a simulated difficult airway scenario 6.
- A study published in 2017 found that the visual analogue scale score for pain in the throat was significantly lower in the video laryngoscopy group than in the laryngeal mask airway with bougie group 5.
- A meta-analysis published in 2024 found that there was no significant difference in complications between the bougie and stylet approaches 2.