Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis - 18/01/24
Abstract |
The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded. A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level. We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty). In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.
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| Please see page 133 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Michael Gottlieb, MD. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: RVH and LOJS conceived and designed the study. DJG performed the literature search. RVH, NF, and LOJS screened the identified articles. RVH and LOJS assessed the eligibility of the studies. RVH performed data extraction and quality analysis, which LOJS supervised. RVH and LOJS managed the data. RVH and LOJS analyzed the data. RVH, LOJS, and IWAM drafted the article, and all authors contributed substantially to its revision. FB and DP provided content expertise about this topic. LOJS takes responsibility for the paper as a whole. |
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| Data sharing statement: Data supporting this study's findings are not publicly accessible due to privacy reasons but can be requested from the corresponding author. Shared data will be de-identified to protect participant confidentiality. Derived data, the study protocol, statistical analysis plan, and analytic code can also be provided on request, promoting transparency and reproducibility. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals' policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). This study received no funding. The authors report no conflicts of interest. |
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| A podcast for this article is available at www.annemergmed.com. |
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| Continuing Medical Education exam for this article is available at learn.acep.org/. |
Vol 83 - N° 2
P. 132-144 - février 2024 Retour au numéro
Article précédent
- Influence of Patient and Clinician Gender on Emergency Department HEART Scores: A Secondary Analysis of a Prospective Observational Trial
- Rebecca Barron, Timothy J. Mader, Alexander Knee, Donna Wilson, Jeannette Wolfe, Seth R. Gemme, Stacey Dybas, William E. Soares
- Bougie First: Rethinking the Modern Airway Algorithm
- Michael Gottlieb, Megan Fix
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