To bougie or not to bougie as a first attempt intubation – and what is a bougie anyhow?!
Myron Yaster MD and Melissa Brooks Peterson MD
Many years ago, at a trauma conference I attended, a speaker from the Maryland Shock Trauma center stated that “gum-elastic bougie facilitated intubation was their standard for emergency tracheal intubation” and/or “was always available as a first-line rescue if standard direct laryngoscopy with a conventional styleted endotracheal tube failed”. I must admit that I found this surprising, because although I had been taught and practiced how to use the bougie for failed intubations, I had never used one of them as a first attempt technique in normal patients and only occasionally used it “in combat” (trauma). On the other hand, in the past, a unique optical stylet became a well-established technique in infants with craniofacial anomalies (like Pierre Robin syndrome).1 However, the optical stylet has fallen out of routine practice since the introduction of video laryngoscopy and I’m not really sure if they even exist today.
In today’s single center, retrospective observational study, the authors compared the use of gum elastic bougies vs standard stylets in first attempt tracheal intubation in pediatric patients intubated in an emergency department by emergency medicine residents.2 Unfortunately, this study does not provide definitive answers to the question of which method was more effective or safer. Indeed, it raised more questions than answers. So why did I pick this article for the PAAD? Because it is my hope that one or more of you will use this study as a blueprint to conduct a future randomized controlled, multi-institutional trial or survey to look into this issue in much greater detail. But more about that at the conclusion of the PAAD. Myron Yaster MD
Original article
Prekker ME, Bjorklund AR, Myers C, Harvey L, Horton GB, Goldstein J, Usher SC, Reardon RF, Robinson A, Strobel AM, Driver BE. The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children. Ann Emerg Med. 2023 Jun;81(6):667-676. doi: 10.1016/j.annemergmed.2023.01.016. Epub 2023 Feb 24. PMID: 36841658.
“Existing data describing the benefits of bougie use in children is scant and is mostly limited to case reports, case series, or manikin studies.”2,3 This single center, retrospective study conducted in a mixed adult and pediatric emergency department, looked at first attempt successful intubations in children ages 1.7-9 years of age (median 5 years) performed by 3rd year emergency medicine using a bougie as first attempt technique compared to non-bougie use. It was not associated with improved success.
As the authors point out there were an enormous number of problems/limitations with this study – and we agree. It is a single center(Hennepin County Medical Center, University of Minnesota), was not randomized, and methodology for chosing one technique versus the other is not known. The pediatric experience of the PGY-3 adult emergency medicine residents performing most intubations was also unclear and unknown. Finally, because this study was performed on data collected over 10 years, many, but not all of the intubations, were performed with video laryngoscopy. Also, with that length of time, presumably the approach and available devices changed over a decade and this was not measured. Indeed, the authors recommend the use of videolaryngoscopy in any future randomized trial because in this study, “one-third of failed first intubation attempts were because of poor laryngeal view.” Further, “video laryngoscopy could facilitate investigators in their evaluation of the heterogeneity of treatment effect by the quality of the laryngoscopic view achieved and any mechanical complications of intubation.”2 I (Melissa) actually thinks this study, analysis, conclusion and discussion should simply stop here. The conclusion of this study, like many of the others we are all familiar with is: Video laryngoscopy facilitates the quality of the laryngoscopic view and helps to avoid complications of mechanical ventilation. (Period!)
There is one other point of discussion that is important for us to know as airway experts – though admittedly, Myron, made this mistake and I (Melissa) pointed it out. It turns out – a “gum elastic bougie” is total misnomer (say what?!?!). What we colloquially refer to as a “bougie” is actually an “Eschmann endotracheal tube introducer”. So we are clear on what we are talking about here: the light blue colored, stiff but coated in a smooth plastic, “slick stick” that has a bend in it. When you advance it into the trachea, it provides some tactile feedback of a gently “clunk clunk clunk” as you glide over the cartilaginous rings of the trachea. So you know if you are in the trachea before you have chest rise, condensation in the ETT, or ET CO2.
Regarding the misnomer, ee can’t say it any better than this letter to the editor from 2004:
“The gum elastic bougie is a urinary catheter that was originally used for dilation of urethral strictures. This catheter was used as an endotracheal tube introducer (to facilitate difficult tracheal intubation) by Sir Robert R. Macintosh in 1949. Inspired by Macintosh’s report, Venn designed the currently used introducer in the early 1970s. He was then the anesthetic advisor to the British firm Eschmann Bros. & Walsh, Ltd. of Shoreham-by-Sea, West Sussex, United Kingdom, which accepted the design in March 1973. The material of the newly designed introducer was different from that of a gum elastic bougie in that it had two layers: a core of tube woven from polyester threads and an outer resin layer. This provided more stiffness but maintained the flexibility and the slippery surface. Other differences were the length (the new introducer was 60 cm, which is much longer than the gum elastic bougie, thus facilitating endotracheal tube railroading over it) and the presence of a 35° curved tip, permitting it to be steered around obstacles. The Eschmann endotracheal tube introducer went into production shortly after design acceptance in 1973, and all three design differences (material, length, and curved tip) have contributed throughout the years to the reported success with its use and widespread popularity. As has been previously pointed out by Viswanathan et al. in a review article, the Eschmann endotracheal tube introducer is not made of gum, is not elastic, and is not used as a bougie. Because of these differences between the two devices in design and function, we strongly recommend that the Eschmann endotracheal tube introducer should no longer be referred to as a gum elastic bougie.“4
Here's the rub though….. if you ask for an “Eschmann endotracheal tube introducer” in a difficult airway situation or a code, you are likely to have nothing handed over to you and a series of confused faces staring blankly back at you. So, perhaps you will still have to ask for a “bougie” but please know and teach that it’s not a bougie!!
I (Melissa) think this should be our conclusions from the mash up of these two papers. (1) We know videolaryngoscopy is the way to go if you can have easy, fast access to these superior devices. The first study doesn’t offer much more data than that! (2) the real utility of an Eschmann endotracheal tube introducer is that it rolls up nicely into a code bag or a backpack – and it’s much easier to run to a code with a small code bag as opposed to rolling a videolaryngoscope! And (3) Ask for a Bougie if its an emergency or say “May I please have the light blue Eschmann endotracheal tube introducer, the Bougie?” in an emergency situation. And (4) If you are going to stock this device and use it in an emergency, practice with it every now and then, and teach your trainees to use it as well! It shouldn’t be your primary device, but it should be in your armamentarium.
Let us know what you think about this PAAD, and we will post in a reader response! –Melissa and Myron
References
1. Cook-Sather SD, Schreiner MS: A simple homemade lighted stylet for neonates and infants: a description and case report of its use in an infant with the Pierre Robin anomalad. Paediatr.Anaesth. 1997; 7: 233-235
2. Prekker ME, Bjorklund AR, Myers C, Harvey L, Horton GB, Goldstein J, Usher SC, Reardon RF, Robinson A, Strobel AM, Driver BE: The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children. Ann Emerg Med 2023; 81: 667-676
3. Semjen F, Bordes M, Cros A-M: Intubation of infants with Pierre Robin syndrome: the use of the paraglossal approach combined with a gum-elastic bougie in six consecutive cases. Anaesthesia 2008; 63: 147-150
4. El-Orbany Mohammad I, Salem M R, Joseph Ninos J: The Eschmann Tracheal Tube Introducer Is Not Gum, Elastic, or a Bougie. Anesthesiology 2004; 101: 1240-1240