For Rapid Sequence Intubation (RSI), does the bougie outperform the stylette?

From the Guidelines

The bougie outperforms the stylet for Rapid Sequence Intubation (RSI), particularly in difficult airway scenarios, with improved first-pass success rates as demonstrated in a large randomized controlled trial [ 1 ].

Key Points to Consider

• The bougie, a long, thin, flexible introducer with a curved tip, has been shown to improve first-pass success rates compared to traditional stylets, especially in patients with at least one difficult airway characteristic [ 1 ].
• In a typical RSI sequence, after administering medications for induction and paralysis, the bougie is inserted through the vocal cords, with confirmation of tracheal placement by feeling the characteristic "clicks" as it passes over tracheal rings and encountering resistance at appropriate depth (hold-up sign) [ 1 ].
• The bougie is particularly valuable in cases with limited glottic visualization (Cormack-Lehane grade 2b-3), anterior airways, or when blood or secretions obscure the view, due to its ability to navigate the airway with minimal visualization and provide tactile feedback confirming proper placement [ 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, with a weak recommendation (Grade D) [ 1 ].

Clinical Application

• Providers should maintain proficiency with both bougie and stylet techniques, as certain situations (such as very narrow airways) may favor a stylet approach [ 1 ].
• The choice of technique depends upon the experience of the anaesthetist with a particular technique, and oxygenation should be maintained with mask ventilation between intubation attempts [ 1 ].

From the Research

Comparison of Bougie and Stylette for RSI

• The use of a bougie versus a stylette for Rapid Sequence Intubation (RSI) has been studied in several clinical trials, with varying results.
• A study published in JAMA in 2018 2 found that the use of a bougie resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation, with an absolute difference of 11% (95% CI, 7% to 14%).
• Another study published in The Journal of Emergency Medicine in 2012 3 reported that bougies have high success rates for prehospital providers and first-time emergency department users, with few reported complications.
• However, a more recent study published in JAMA in 2021 4 found that the use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with the use of an endotracheal tube with stylet among critically ill adults undergoing tracheal intubation.
• A meta-analysis published in The Journal of Trauma and Acute Care Surgery in 2019 5 found that endotracheal intubation performed with a bougie was not superior to ETI performed with a stylet, and that intubation approaches should be selected based on personal preference and clinician expertise.

Key Findings

• The bougie may be associated with higher first-attempt intubation success in certain patient populations, such as those with difficult airways 2.
• The use of a bougie may not be superior to the use of a stylette in all cases, and the choice of intubation aid may depend on individual patient factors and clinician preference 4, 5.
• Further research is needed to fully understand the benefits and limitations of using a bougie versus a stylette for RSI.

Study Limitations

• The studies had different patient populations, settings, and outcomes, which may limit the generalizability of the results 2, 4, 5.
• The studies may have been subject to bias, such as selection bias or confounding variables, which could have affected the results 2, 4.