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Gum elastic bougies in difficult intubation

Three Part Question

[In patients in with a poor laryngoscopic view] is [use of a gum elastic bougie better than simply using the ET tube] at [successfully and quickly achieving tracheal intubation]?

Clinical Scenario

A 55 year old female is brought to the emergency department following an overdose of alcohol and tricyclic antidepressants. She has a tachycardia (110) and a systolic blood pressure of 105mmHg. The GCS is 5 (extends to pain). You decide to do an RSI using etomidate and suxamethonium. You are only able to visualise the epiglottis at laryngoscopy (Cormack grade 3 view), and struggle to intubate the patient on the third attempt (having intubated the oesophagus twice). You wonder if it would have been easier if you had used a gum-elastic bougie.

Search Strategy

Medline 196607/2001 using the OVID interface.
[{exp laryngoscopy OR laryngoscopy.mp OR exp intubation, intratracheal OR intubation.mp OR intubate$.mp} AND {bougie$ OR gum elastic.mp}] LIMIT to human AND English.

Search Outcome

78 papers were found of which 1 directly answered the three part question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Nolan JP,
1993,
UK
157 patients undergoing elective surgery Patients were intubated in the neutral c-spine positionPatients were either intubated direct (just with the ETT) or using a bougie.PRCTNumber of grade 3 views in neutral position34/157 (22%)Small number of truly difficult laryngoscopies in whom differences are likely to be the greatest No grade 4 views
Median time for intubation20 secs for direct intubation vs. 25 seconds for use of the bougie
Success rate for intubation5/78 (6.4%) direct intubation patients could not be intubated (they were subsequently intubated using the bougie. 0/79 patients could not be intubated using the bougie
Number of patients requiring prolonged time for intubation (>45 seconds)11 in direct visualized group vs none in the bougie group.

Comment(s)

Although the mean time for intubation is longer with the bougie the difference is clinically unimportant. Of greater interest is the number of patients who could not be intubated directly, but who were subsequently intubated using the bougie. Similarly, there were no prolonged intubation times in the bougie group. Use of a gum-elastic bougie appears to ease intubation in a neutral c-spine position.

Clinical Bottom Line

A gum elastic bougie should be available as an aid to intubation during difficult laryngoscopy.

References

  1. Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum-elastic bougie. Anaesthesia 1993;48:630-633.