Bougie vs. Rigid Stylet for Pre-Hospital Intubations
For pre-hospital intubations in medically unstable patients with potentially difficult airways, the bougie demonstrates superior first-pass success rates compared to rigid stylets, particularly when difficult airway characteristics are present.
Primary Recommendation
Use a bougie as the first-line adjunct for pre-hospital intubations rather than reserving it as a rescue device. The most recent and highest-quality evidence from a 2024 systematic review and meta-analysis demonstrates that bougie use is associated with increased first-attempt intubation success (pooled risk ratio 1.11,95% CI 1.06-1.17) across all settings, with the strongest benefit seen in patients with Cormack-Lehane grade III or IV views (risk ratio 1.60,95% CI 1.40-1.84) 1.
Evidence-Based Rationale
Emergency and Pre-Hospital Settings
In emergency department intubations by residents, a large randomized controlled trial (n=757) found bougie use increased first-pass success to 96% versus 82% with stylets in patients with at least one difficult airway characteristic (absolute difference 14%, 95% CI 8-20%) 2.
For patients requiring cervical spine immobilization (a common pre-hospital scenario), the bougie showed even greater benefit with an absolute difference of 22% (95% CI 9-36%) in first-pass success compared to stylets 2.
The 2022 ASA Practice Guidelines specifically note observational findings showing 96% first-attempt success with bougies versus 82% with stylets in emergency department difficult airways 2.
Mechanism of Superiority
The bougie is more effective than stylets when the laryngeal view is Cormack-Lehane grade 3, as it can be passed blindly into the trachea when the laryngeal inlet is not fully visible 2.
The bougie's design features—60 cm length, angled tip, and combination of flexibility and malleability—allow for tactile confirmation of tracheal placement through tracheal clicks, distal hold-up in the bronchial tree, or coughing 2.
Success rates with the original reusable bougie in prospective studies have ranged from 94.3% to 100% 2.
Video Technology Considerations
When video laryngoscopy is available in pre-hospital settings, a 2022 systematic review found bougies offer statistically significant advantage in first-pass success (RR 1.15, CI 1.10-1.21, p<0.0001) 3.
A 2024 randomized trial using hyperangulated videolaryngoscopes showed 98% first-attempt success with bougie versus 88% with stylet (p=0.032) in patients with predicted difficult airways 4.
A 2025 ICU study using hyperangulated blade videolaryngoscopy demonstrated 99% first-attempt success with flexible-tip bougie versus 83% with stylet (p=0.005) 5.
Clinical Application Algorithm
Step 1: Initial Assessment
- Recognize pre-hospital intubations as inherently difficult due to patient instability, limited positioning options, and environmental constraints 2.
Step 2: Equipment Selection
- Select bougie as primary adjunct rather than stylet for first intubation attempt 1.
- If video laryngoscopy is available, use it with the bougie for optimal success 3.
Step 3: Technique Optimization
- Keep the laryngoscope in the mouth during bougie insertion and tube railroading 2.
- Advance bougie to maximum 45 cm, feeling for tracheal clicks or distal hold-up 2.
- Rotate the endotracheal tube 90° anticlockwise during railroading to facilitate passage 2.
Step 4: Confirmation
- If no clicks, hold-up, or coughing are elicited, the bougie is likely in the esophagus—remove and reattempt 2.
Important Caveats and Pitfalls
Limitations of Bougie Technique
- The bougie has limited value when the epiglottis cannot be elevated (grade 3b) or visualized (grade 4) 2.
- Critical pitfall: Some single-use disposable bougies may not be as effective as the original multiple-use bougie and may cause more trauma 2.
Time Considerations
- While stylets may lead to shorter time to intubation in some scenarios, this advantage is outweighed by lower first-pass success rates 3, 6.
- In a simulated grade 3 view, mean time to intubation was longer with bougie (116.6s) versus stylet, but success rates trended higher with bougie 6.
When Stylets May Be Considered
- Without video technology available, the difference between bougie and stylet becomes less pronounced, and practitioner experience may guide device selection 3.
- In settings where video laryngoscopy is unavailable and the operator has extensive stylet experience, either device may be acceptable 3.
Guideline Consensus
The 2024 Difficult Airway Society guidelines recommend clinicians should consider using an adjunct such as a stylet or bougie when performing tracheal intubation in patients whose cervical spine is immobilized (Grade D recommendation), though they note the evidence base comparing the two is limited 2. However, the single highest-quality study they cite (Driver et al.) demonstrates clear bougie superiority 2.
The 2004 Difficult Airway Society guidelines explicitly state there is evidence that the bougie is more effective than the stylet when the best view of the larynx is grade 3 2.