Bougie use in Emergency Airway Management (BEAM)

Written by Salim Rezaie REBEL EM Medical Category: Procedures and Skills

Background: Emergency intubation in the ED is a potentially life-saving procedure in critically ill patients, but does have risks associated with it as we have discussed before on this blog. The authors of the study we are going to review today described a first-attempt intubation success (FPS) rate in the ED to be 85%, despite new technologies such as video laryngoscopy [2]. Successful endotracheal intubation on the initial attempt is vital as it reduces the likelihood of adverse events. Use of the bougie as the primary intubation approach may increase FPS but it is typically reserved as a rescue device only after failed intubation attempts. This is the first randomized controlled trial comparing the bougie vs endotracheal tube + stylet (ETT + stylet) in ED patients with at least 1 characteristic predictive of difficult intubation. The trial is titled the Bougie use in Emergency Airway Management (BEAM) trial.

What They Did: This was a single center, randomized clinical trial of consecutive patients, requiring orotracheal intubation with a Macintosh laryngoscope blade, comparing bougie first intubation vs ETT + stylet first intubation among patients with difficult airways undergoing emergency intubation performed by ED physicians.

Patient positioning, preoxygenation strategy, use of neuromuscular blockade (i.e. rapid sequence intubation), cricoid pressure, choice of Macintosh laryngoscope, and whether to view the video screen was all up to the emergency physician.

Outcomes:

Primary: FPS in patients with at least 1 difficult airway characteristic (i.e. body fluids obscuring laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma, or need for cervical immobilization) FPS was defined as successful endotracheal tube placement with the first device passed (bougie or endotracheal tube + stylet) during the first laryngoscope insertion

Secondary: FPS in all patients FPS success without hypoxemia First attempt duration (i.e. time elapsed between insertion and removal of the laryngoscope blade from the patient’s mouth) Esophageal intubation Hypoxemia (i.e. SpO2 <90% or if the attempt began with a saturation <90%, and absolute decrease in desaturation of >10%)



Inclusion:

Adult patients ≥18 years of age

Emergency orotracheal intubation in the ED

Use of a Macintosh laryngoscope blade (Standard geometry blade)

Exclusion:

Prisoners

Pregnant patients

Known distortion of upper airway or glottic structures (i.e. angioedema, epiglottitis, laryngeal mass, or malignancy)

Use of hyperangulated laryngoscope

Results:

757 patients randomized to Macintosh laryngoscope blade intubation for respiratory arrest, difficulty breathing, or airway protection 380 of the patients randomized had at least one difficult airway characteristic Bougie 1 st Intubation = 381 patients (198 had a difficult airway characteristic) ETT + Stylet 1 st Intubation = 376 patients (182 had a difficult airway characteristic)



No difference between groups for any intubation related complications including pneumothorax, aspiration, dental trauma, direct airway trauma, or esophageal intubation

Strengths:

The study asks a clinically important question

Randomization was adequately performed

Data was collected in real time with the use of a stopwatch, increasing accuracy of times recorded

Reporting of FPS was adjudicated by an investigator who retrospectively reviewed video of the captured intubation on motion-activated, ceiling mounted cameras

A trained and blinded abstractor reviewed final postintubation chest x-rays to determine the presence of pneumothorax

Individual physician’s intubation abilities were analyzed post hoc to account for clustering by physician as a physician’s abilities to intubate could affect FPS

An interim analysis evaluating futility was completed at the midpoint of the trial

Adherence to the randomized allocation was 98% in the bougie group and 92% in the ETT + stylet group

Both groups were well balanced in terms of patient characteristics and clinical indications for intubation

Limitations:

Single institution study where bougie 1 st intubation is a common practice. This may not be generalizable to all institutions not as comfortable with the use of the bougie.

intubation is a common practice. This may not be generalizable to all institutions not as comfortable with the use of the bougie. Difficult airway features were determined by the intubating physician subjectively post intubation, but this was performed immediately after intubation minimizing recall bias

For obvious reasons physicians and researchers could not be blinded as to which device was being used for intubation

Patients intubated with hyperangulated laryngoscopes were excluded, therefore the results of this study are not to be applied for these devices

Discussion:

Interestingly, in the bougie group, a bougie was passed into the trachea and if successful, an assistant loaded the endotracheal tube over the bougie and ultimately passed through the vocal cords. In the environments I work in, having an assistant is a luxury that’s frequently absent. This is where a pre-loaded bougie with an ETT, using a Kiwi grip becomes very useful (See image below).

In their exploratory analysis, the bougie appeared to be superior compared to ETT + stylet for FPS in patients with cervical in-line immobilization (100% vs 78%), obese patients (96% vs 75%), and patients with incomplete glottic views on laryngoscopy (97% vs 60%)

31 patients or 7% of the intubations with bougie met resistance from the arytenoid cartilages,but a simple maneuver with the ETT overcame this (see figure below)

Author Conclusion: “In this emergency department, use of a bougie compared with an endotracheal tube + stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation. However, these findings should be considered provisional until the generalizability is assessed in other institutions and settings.”

Clinical Take Home Point: Although, the results of this trial still need to be validated in other ED settings, use of bougie first instead of as a rescue device when using a standard geometry blade should be strongly considered.

References:

Driver BE et al. 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. JAMA 2018. [Epub Ahead of Print] Brown CA et al. Techniques, Success, and Adverse Events of Emergency Department Adult Intubations. Ann Emerg Med 2015. PMID: 25533140

For More Thoughts on This Topic Checkout:

Post Peer Reviewed By: Anand Swaminathan, MD (Twitter: @EMSwami)