Bougies in the ED: Do They Facilitate Intubation?

Sumit Patel, MD


October 30, 2017

Bougies and Intubation Success

In a recent retrospective, observational study, Driver and colleagues[1] reviewed consecutive intubations in an emergency department (ED) at an urban, level 1 academic trauma center during the 2013 calendar year. A total of 543 intubation attempts meeting study criteria were included. Most intubations at this site were performed by emergency medicine (EM) residents (postgraduate year 3 or higher) with attending physicians supervising. Data collection for this study occurred primarily by researcher review of videos recorded of patient care and intubation attempts. At this facility, critically ill patients are primarily treated in a four-bay stabilization area, of which three bays are equipped with motion sensor video cameras. The cameras are linked to patient cardiac and vital sign monitor data. They also record audio.

Video data were reviewed independently by three investigators who attempted to address interobserver variability. The primary outcome was first-pass success for intubation. Of the 543 intubations reviewed, a bougie was used for the first attempt in 435 cases (80%). First-pass intubation success was achieved in 414 of the 435 cases in which a bougie was used (95%). First-pass intubation success was achieved in 93 of the 108 cases in which a bougie was not used on the first attempt (86%). Thus, the difference between the two groups was 9% (95% confidence interval [CI], 2%-16%). In addition to reviewing information about device and equipment used, the researchers also reviewed medical records for patient demographics and clinical care data. Bougie use was associated with higher first-pass success rates even after multivariable analysis (adjusted odds ratio, 2.83; 95% CI, 1.35-5.92) and also when adjusted for video laryngoscopy screen use.


Although this study has distinct limitations, it serves its purpose of demonstrating that the gum elastic bougie, first described by Macintosh in 1949,[2] is an important part of emergency airway management in the ED. To provide evidence showing that the bougie should be used in all or even most intubation attempts in the ED, a prospective clinical trial needs to be conducted. These investigators, however, used the recording capabilities of their facility in an elegant way to obtain data that suggest that routine use of a bougie may be helpful to ED professionals in airway management.

Specific limitations include the fact that the data came from a single site. Moreover, the staff of the ED where the study was conducted tended to use a bougie more frequently than is typical of the average ED in the United States. First-pass intubation success rates for professionals who do not use a bougie as frequently will certainly vary. The researchers quoted data over a specific time period from the National Emergency Airway Registry showing that only 3.5% of initial intubation attempts in EDs used a bougie.

As someone who intubates patients regularly in emergency situations, my goal is to maximize my first-pass success; we all share that desire. If it means I should change my habits to incorporate a device as inexpensive as a bougie, which carries a low risk for harm, perhaps this is something to consider. Every department is different, and every professional is different. The investigators of this study stated that they were not claiming that the bougie should be used routinely in all intubation attempts but that with more research, the evidence might actually show that someday.

For now, this study is important for us to be aware of. In my practice as an EM trainee who will soon be practicing independently, this study does change my viewpoint of the bougie from a second-line or adjunct tool to a tool that I should perhaps be reaching for more often to maximize my first-pass intubation success rate.


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