The Bougie, has been around for a number of years now. Actually, bougie is a generic name for a number of devices that are shaped like an Algerian candle. Don’t ask.
The one I am talking about today is more formally known as the tracheal tube introducer. Originally developed as an easy way to change ET Tubes in ICU and other units. At some point, about 15 years or so ago the device made it’s way to EMS. Anyone who practiced in the days before any sort of video laryngoscopes were around knows that it can be tough, sometimes impossible to intubate some patients in the field.
As a rule, paramedics are pretty good at intubating under less than ideal circumstances. When we learned to intubate actual patients in the hospital we generally did so in the Operating Room. Conditions in the operating room are ideal for intubation. At least most of the time when the surgery is pre scheduled and the patient has been fully prepped.
The patient has been evaluated prior to going into the OR, so you have a good idea of what difficulties you might face. The light is great, and adjustable. The height of the patient and the person intubating can be adjusted. The patient has been medicated. The patient’s head has been put on a cute little pillow to put the patient’s head at the right angle. It’s nice and clean in there, well sterile actually. Oh, you have trained help standing literally at your shoulder to do anything you need. Did I mention that the patient hasn’t eaten in the 6-8 hours before the surgery is scheduled.
Mostly you don’t have those advantages in the field. I won’t go into stories of intubating patients trapped in an upside down burning car, that is floating down a river towards a waterfall or BS like that. I think I intubated one patient sitting up right in a car in my career. Or maybe it was my partner, I really don’t remember. I did intubate a patient inside a building that was on fire. The Sorta Big City FD had dragged her out of a smoke filled room, down a flight of stairs, and dropped her in the hallway for us to treat. I’m not sure why I elected to intubate her there, but since the fire was two floors above us, the risk wasn’t all that high.
Anyway my point, to the extent I have one, is that field intubations are much different than in hospital intubations. More challenging for the most part. Which is why paramedics who work in busy systems generally have very good airway management skills.
Back to the Bougie. When my former system first adopted them, a lot of us were skeptical to say the least. Since individually each paramedic usually had more than one intubation a month, we were pretty proficient. Since we were one of the very few systems in the state allowed to use drugs to facilitate intubation, every intubation attempt was reviewed by our medical director. That was every one of them, whether medications were used or not.
What’s a good word for scrutiny?
While we were beating our chests about how great we were at intubation and airway control, something happened. Well, a couple of things. First we had some promotions, resignations, and retirements among paramedics. Some of the more senior people were no longer treating patients, so they weren’t intubating. The people promoted to replace them weren’t as experienced or proficient.
So, our success rate dropped.
Then, one of the other great innovations in EMS, CPAP was finally approved by the clerks and secretaries who seem to determine medical policy in my state. We were just about the last state in the union to allow paramedics to use CPAP. Even though in about half of the other states, it was considered a BLS level skill, our clerks and secretaries wanted more studies because as you know, human anatomy and physiology differ once you cross state lines.
Once the administrivia was out of the way, we started using CPAP. We liked it, the patient’s liked it, the hospitals liked it. The insurance companies loved it because CPAP resulted in fewer hospital days and complications than intubation. Winners all around.
The only problem was that we were intubating fewer patients, especially fewer living patients. While good for the patients, it was bad for intubation proficiency.
Which brings us back to the Bougie. We started to use it and our success rate went up. Some people, including yours truly, initially only used it on difficult patients. Which meant that we were making a second attempt since we had failed on the first.
After a little bit of time passed, more medics started using the Bougie on the first attempt for every patient. That really improved our first attempt success rate. In addition to being a number, intubating on the first pass is likely to be better for the patient.
Eventually, most of us started using the Bougie and stopped using stylets. Which I generally didn’t use, but stopped using completely once I mastered the not that difficult task of using the Bougie.
Which brings me to this link,
Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial.
Among 757 patients who were randomized (mean age, 46 years; women, 230 [30%]), 757 patients (100%) completed the trial. Among the 380 patients with at least 1 difficult airway characteristic, first-attempt intubation success was higher in the bougie group (96%) than in the endotracheal tube + stylet group (82%) (absolute between-group difference, 14% [95% CI, 8% to 20%]). Among all patients, first-attempt intubation success in the bougie group (98%) was higher than the endotracheal tube + stylet group (87%) (absolute difference, 11% [95% CI, 7% to 14%]). The median duration of the first intubation attempt (38 seconds vs 36 seconds) and the incidence of hypoxemia (13% vs 14%) did not differ significantly between the bougie and endotracheal tube + stylet groups.
This was an Emergency Department study, not an EMS study. EDs intubations are somewhere between OR and field intubations in terms of conditions and difficulty. Will these results transfer into the field?
I’m not sure it matters. The Bougie is a great airway management tool. It helps in the pre hospital setting, even now when video laryngoscopes are readily available and not insanely expensive.
It’s a simple and inexpensive device, yet it can have a huge impact on patients and makes providers lives far easier.
There are far more expensive devices in EMS that do far less for patients. They might be cool and sexy, but they really don’t improve patient outcomes.
Which, in medicine is the measure of the true value of a device.