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• W4386584129 abstract "Figure: bougie, intubationFigurePlan for the worst, hope for the best. This ethos in many ways gets right at the heart of what we do every day in the ED. I'm hoping that the epigastric pain in a 50-year-old was just from his unfortunate (but completely understandable) decision to have a bag of Flamin' Hot Cheetos and a Big Gulp Mountain Dew for lunch, but I'm also going to make sure he is not having a STEMI before I send him on his way. Similarly, we hope to get a five-second, first-pass intubation on every airway we manage, but the wise and well-trained among us know it's smart to have plans A, B, and C ready in case the easy-appearing airway turns out to be trickier than expected or the anticipated difficult airway decides to live up to its billing. An ED-based study that looked at the use of bougies in 543 intubations (435 with a bougie, 108 without). (Ann Emerg Med. 2017;70[4]:473.) They found that the first-pass success rate was higher when a bougie was used (95% v. 86%; absolute difference, 9% [95% confidence interval (CI), 2%-16%]), giving us a not-so-shoddy NNT of 11 for increased first-pass success when using our gum elastic adjunct. All of this is pretty great, but there was a boatload of caveats that weigh down, if not completely burst, our bougie balloon: This was a retrospective, single-center study at an institution that is clearly already on Team Bougie with 80 percent of all first intubation attempts being done with the assistance of this device. EBM Prevails Thankfully, the authors heard the cries of the skeptics and evidence-based medicine aficionados, and plowed forward with a high-quality prospective study that also managed to make use of a cool-sounding acronym: BEAM, or Bougie Use in Emergency Airway Management. (JAMA. 2018;319[21]:2179; http://bit.ly/3bfU0Q7.) This time around, emergency physicians were randomized to intubate using a bougie or an endotracheal tube with a stylet. The study population was 757 patients, just more than half of whom (380) had at least one difficult airway characteristic (body fluids obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or the need for cervical spine immobilization). For all comers, the authors found that first-attempt intubation success in the bougie group (98%) was higher than that in the endotracheal tube and stylet group (87%) (absolute difference, 11% [95% CI, 7%-14%]). That difference jumped to 14 percent (95% CI, 8%-20%) for patients with difficult airway characteristics. This yields NNTs of 9 and 7, respectively, for bougie use overall and in patients with difficult airway characteristics. Note that the study found no significant difference in time to intubation or in hypoxia between the two groups. I guess you could say that the authors demonstrated using a bougie right off the bat is never going to steer us wrong (sorry, not sorry). This may look cut and dried, but critics would rightly note that these studies were done at the same institution, one with a high baseline rate of bougie use, and, importantly, that almost all (96%) of the intubations in the BEAM trial were done using a video laryngoscope. On top of this, we know that the environment and resources at an academic medical center aren't necessarily representative of conditions in EDs around the country. Safe and Effective Addressing these concerns from a slightly unexpected angle is a new paper examining the impact of routine bougie use among field intubations by paramedics in the Seattle Fire Department, which is the sole EMS provider for the city. (Ann Emerg Med. 2020 Dec 17; https://bit.ly/3bez8IK.) They prospectively studied intubations over an 18-month period without routine bougie use and then an 18-month period where the protocol called for bougie use on the first attempt. A total of 823 patients were in the control period and 771 during the bougie phase. The first-attempt success rate increased from 70 percent to 77 percent (difference 7.0% [95% CI, 3%-11%]). Here we have an NNT of 15 for additional first-pass success—and in a challenging clinical environment, often with CPR in progress and no video laryngoscope in sight. The benefit was present whether or not the airway was difficult, and it was consistent across all levels of cord visualization. Unlike the hospital in the earlier studies, routine bougie use was not common practice among these paramedics (8.9% of patients had first attempt with a bougie in the control period compared with 81.3% of patients in the bougie period). So we have three studies in two different settings, and all tell a consistent story: Routine bougie use is better. It increases first-attempt success rate in easy airways and difficult ones. It doesn't lead to increased complications or adverse outcomes. It appears to work with direct and assisted video laryngoscopy, and it's effective in and out of the hospital. Oh, and bougies are cheap ($10 or less). It's rare in medicine that we find an intervention that is safe, effective, and affordable, so the next time you tube, bet on the bougie. Dr. Rundeis the assistant residency director and an assistant professor of emergency medicine at the University of Iowa Hospitals and Clinics, where he serves as co-director for the associate fellowship in medical education. He creates content for and is a member of the editorial board forwww.TheNNT.com, and is a content contributor forwww.MDCalc.com. Follow him on Twitter@Runde_MC, and read his past articles athttp://bit.ly/EMN-ReasonableDoubt." @default.
• W4386584129 created "2023-09-11" @default.
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• W4386584129 date "2021-02-01" @default.
• W4386584129 modified "2023-09-29" @default.
• W4386584129 title "Reasonable Doubt" @default.
• W4386584129 doi "https://doi.org/10.1097/01.eem.0000734592.86823.a3" @default.
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