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Three Part Question

In a [restricted view intubation] is the [gum elastic bougie more effective than a stylet] at [improving the intubation success rate]?

Clinical Scenario

A paramedic ambulance is dispatched to a 36-year-old female who has fallen from a horse. On arrival the rider is not wearing a helmet, is unconscious with a GCS of 3 and has laboured diaphragmatic breathing. A cervical spine injury is suspected and orotracheal intubation is indicated due to the reduced respiratory effort, possible head injury and the long transport time to the nearest emergency department. The patient has a grade 3 laryngoscopic view (Cormack and Lehane). You wonder whether intubation would be made easier if you had a gum elastic bougie or stylet.

Search Strategy

Medline and HealthStar 1966-06/02 using the OVID interface.
[{exp intubation, intratracheal OR intubat$.mp OR intubation$.mp OR exp intubation OR exp laryngoscopy OR laryngospcopy.mp} AND {introducer.mp OR bougie$.mp OR gum elastic.mp OR stylet$.mp}] LIMIT to human AND English.

Search Outcome

334 papers found of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gataure PS et al, 1996, UK	100 patients undergoing elective surgery randomly split into 2 equal groups. Group 1 were intubated using 2 attempts with a bougie followed by a stylet while group 2 were intubated with 2 attempts with a stylet followed by a bougie. Simulated grade 3 views were used. Bougie vs stylet	RCT	Success rate after 2 attempts	48/50 (96%) vs 33/50 (66%) p < 0.001	Not tested with grade 4 views The study did not compare lighted stylets against bougies and unlighted stylets The study used simulated difficult intubations rather than actual difficult intubations
			Mean time for 2 intubation	30.1 sec vs 36.6 sec

Comment(s)

The use of simulated views is less than ideal. Despite this drawback the results clearly answer the question posed. A further study comparing the bougie, the lighted and unlighted stylet in both grade 3 and grade 4 views would be useful.

Clinical Bottom Line

The gum elastic bougie is superior to the stylet at increasing the intubation success rate, when tested on simulated grade 3 views.

References

1. Gataure PS, Vaughan RS, Latto IP. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Anaesthesia 1996; 51(10):935-938.