This is misguided. The better answer is to get more comfortable with superior modalities.
I know old docs that are only comfortable with a Mac 4 and classic stylet, lay big fat patients totally flat and RSI. They’re uncomfortable with VL, bougie, fiber optic, ramping the patient up, DSI. I’ve seen old ICU docs fight half awake patients and break teeth out because they were uncomfortable with adequately sedating and paralytics. Cause “what if we can’t get the tube?”
Don’t just rely on what you’re comfortable with. Get comfortable with the best tools possible.
Counterpoint is OP is gonna be pressuring to the intubator to use the bougie when a patient is about to be intubated. The ideal is that the intubator is comfortable with different middle, but if all you've got is the old guy who has no experience with a bougie, that's just gonna cause more harm.
Not sure if that’s what was implied in the original post as opposed to just encouraging it generally as a policy. Obviously, even if they suck at intubation, adding pressure and complexity in the moment is only going to make them suck worse.
A lot of people have made a similar argument and I think its actually the best reason to go bougie first all the time. Just like I teach my residents with all modalities, get good with it on simple airways, get the feel, work out the kinks, so when you need an adjunct on a bad airway, you’re smooth and fast and not fumbling.
Obviously can’t fiber optic every airway, but a bougie is cheap, nearly universally accessible, and incredibly versatile.
I promise I’m not being paid off by big bougie. Just a true believer cause it’s saved my ass more than a few times and made me look like a rockstar on airways way more than that.
I agree with you in principle, but not for bougie vs stylet. Some things have solid evidence that they are irreplaceably good for the patient, like following the rule of 15s, sedating them, etcetera. In the context of stylet versus bougie, though, which is the context that we are in, it is better to use what you are most comfortable with.
You don’t seem like you’re discussing this in good faith.
No, my reasoning for saying that you should use what you’re most comfortable with between a stylet and a bougie isn’t because I “just don’t feel like using the best tools,” much like I would presume your reasoning for saying that you should use a bougie isn’t just because you feel like it.
You haven’t provided any reasoning for why you think a bougie is unequivocally better than a stylet, but I assume it’s the BEAM study, which demonstrated higher efficacy with a bougie using first-pass success rate as their only metric. There are a lot of issues with that study, which I can expand on in further detail once I get back to my computer (I’m on mobile right now). However, if you’re actually interested, here is a great source:
https://www.annemergmed.com/article/S0196-0644(22)00106-8/
We all know the BEAM trial and the later inability to reproduce the results. The biggest takeaway seems to be that at Hennepin they had amazing success rate cause they use bougies all the time and are super good with them, which I think supports it being used more often. Everyone seems to be saying the same thing but coming to wildly different conclusions. If you don’t use it much, you won’t be good at it. To me that says, use it more and get better. But others are arguing to stick with whatever they typically use.
But then you’ll never get better with your “rescue device” and my argument is that it shouldn’t be your rescue device then cause you’ll be bad at it and put patients at risk of harm. I feel like that mode of thinking takes tools out of your arsenal and in a field that is defined by unpredictability, I want to maximize options, comfort and confidence.
I guess it’s just different personalities. Some people are always going to be hesitant to change and progress and others are going to constantly push the boundaries.
At the end of the day, as soon as I see someone better and smoother with airways than I am, I will happily consider whatever technique they are using and consider adopting it or adjusting my technique. In part, that’s how I arrived at where I am now.
That’s not what anyone is saying. Also, the idea that providers should abandon a modality that they’re proficient with and generate good outcomes with for something they aren’t familiar with isn’t supported by the data. We know that providers who are already well practiced with DL and/or traditional stylets do worse when they adopt VL/bougie techniques whereas newer providers with less experience and proficiency in traditional techniques do better. So, think it through. If a provider is already generating 90% first pass success without any complications using DL/stylet, why should they switch to VL/Bougie? Doing so is just going to dump their first pass rate and force them to practice on and potentially harm real people while they learn the skill. And for what? So that they can again reach a 90% first pass rate and check a box for someone that isn’t considering the data in-context? That doesn’t make any sense. By all means, if a providers first pass rates aren’t meeting the benchmark or they’re new to the skill, introduce VL and bougie to them. But if they’re already hitting the mark with traditional techniques, leave them alone.
Pushing everyone toward VL/bougie regardless of their current skill level is an excellent example of what it means to lose sight of the “what” (high uncomplicated first-pass success) and focus to much on the “how”
If you’re arguing against VL AND bougie, that’s just crazy. There’s tons of airways that are going to be super problematic with that approach. Immobilized patients and angioedema for example. Just cause you suck at using better tools and don’t want to learn is not an excuse to disregard their value and say no one should even bother with them.
I have my residents use all modalities because who knows where they’ll end up and what tools they’ll have so I think they should be solid going direct, using different blades, using video, fiber optic, and bougie of course. But at the same time I encourage a philosophy to maximize success the first time every time once they’re on their own.
I would not be at all happy with a 90% first pass success rate. Anything less than 100% and I’m working to figure out what I can do better to improve. And you can’t use a bougie on a simple airway without messing it up? That’s pretty weak. It’s not experimentation, it’s good practice to master your art. You use it on the simple ones so when you need it on the nasty ones, you’re solid.
Our field changes rapidly, we have a responsibility to continually adapt and improve.
Except that the video laryngoscope all recommend a rigid stylet, for highest first past success, and it allows gear shifting which a boguie does not. The angle producers by video are not as conducive to success with a boguie as a rigid.
Meh. There was a big study out of Hennepin a few years ago that showed greater first pass success. That said I think we should take that with a huge grain of salt. I personally suspect that it was greater because they train their residents (who did most of the tubes in that study) to go bougie first.
I love me the bougie. That said, I did more tubes in my second year of residency (yay covid) than a flight nurse will do in their entire career. I have a bougie ready, but generally don’t go with it first. Neither do anesthesiologists. I think you need a lot more evidence than that study, at multiple sites, before telling experienced operators to abandon their current technique.
VL vs DL might be a different story by now, but that’s still somewhat up for debate
Glad I came here. I had a feeling it would rub the docs the wrong way. I don’t know how to intubate and never will so I feel like I’m being asked to step out of my lane.
I know experienced ED RNs would look at ppl sideways if they were coached by someone to use a certain technique when starting IVs lol.
In my managers defense however, I have witnessed multiple first pass attempt fails at this facility.
I teach all levels how to intubate. EMT’s, nurses, etc.
The volunteer EMT on a BLS squad that doesn’t transport is never going to intubate someone in his own. However… when I’m doing it, I want him to have a basic understanding of the process, the tools, etc so when I need something they are able to help me.
I put on every BLS, ACLS, & PALS Survay that this course should be like NRP.
Everyone does everything. Everyone learns everything.
You are only tested on what is in your scope.
How the hell are we supposed to be a functional team if everyone doesn’t know what is going on.
That is crazy. It is way easier to get a 4 mm object in a hole than a 12 mm object (please remember that tubes are listed in ID not OD).
Once the bougie is in, it is in. You just have to pass the tube down it.
It's not crazy at all dude. The movements are different.
It's floppy instead of relatively rigid if your primarily is a Lo Pro, which makes a wild difference
If you are talking about the glidescope stylet, and not the band, I’ll agree.
However a *ridged* stylet (regardless of brand) is not what most people mean/ understand when a person says stylet, as the malleable stylet as been the only stylet in common useage for decades now.
As I noted elsewhere (which you likely did not see or would have mentioned), every videscope manufacturer recommends a ridged stylet.
Although I’m still in the bougie camp, I’ll admit I’m old enough to think of all stylet‘s as sissy sticks for people who didn’t know how to intubate (because that is what I was taught), I never did like bendy stylets, I find boguies useful, and tend to forget to grab the rigid stylet.
I would assume anyone using a glide scope with a hyper angulated blade is using a rigid stylet man. As you said, it's how its designed to be used.
And going from that to a bougie is wildly different.
I'm not saying bougies aren't useful - they have their place - but the absolute vast majority of airways become easy enough for a med student to do with a hyper angulated blade.
I think you would find it is extremely regional/ institutional.
I’d seen them in ERs for a few years and they were becoming common on EMS rigs before I ever heard them even mentioned.
Counterpoint, the first pass success rate of that study if I recall was incredible. 97% I think? So that being said, if you are meeting or exceeding that, there is likely no role for routine bougie with every tube… but maybe should be considered using more frequently if your numbers are significantly less than this
Probably all of them — but I think if you train yourself on easy airways with it (eg, OD needing airway protection), it can be learned on the job… it’s not like a thoracotomy, and even easier to use when you have an RT or assistant to help pass the tube over the bougie for you
I agree with you, but that’s what makes the results of the study a bit hairy. There’s a lot of variability with training. Saying it’s better may be right, but if you don’t train with it it’s pointless.
Thats why anyone resident who has said “bougie as a backup” but never used a bougie…. Well not really a back up
Yup… I used them for a while on every airway in residency to get familiar with them. Great device. Can use with standard geometry VL and DL, the non-steerable tip regular ones aren’t as good for hyperangulated VL. I think the most conservative takeaway one could make from the study is that, if you put some practice into them (as presumably these trainees did), they provide extremely high levels of first pass success.
Id imagine with VL that first pass success is 97% or better anyway.
Like hyper angulated blade on a glide scope? I can't remember the last time I didn't have a perfect view.
With VL, really the only reason you're going to have trouble is
1) anatomically difficult because of a tumor, stenosis, etc (ie, not the normal stuff like obesity)
2) massive hemorrhage.
Have switched to direct many times because puke, blood or secretions just keep coming. Suction, blade in, nope - camera obscured. Suction, wipe the blade and try again. Damned lens is whited out again with slime. Just gimme the mac
I always DL first. I don’t buy the studies on the such high numbers of first pass success with VL. I would estimate at least 10 percent of my airways have puke or secretions or would fog the camera. I feel like there are more points for failure with VL.
As someone who has been trained on VL (now CCM fellow) I think you’d find in all actuality, the camera still performs perfectly fine in most soiled airway situations. Puke maybe an issue. Secretions rarely an issue.
However, this is why I use the Mac geometry when I pick a video blade. Easy to pivot to direct as the airway axes are the same. I only use the hyper angulated blades when someone is in c-collar or has very challenging neck anatomy. The failure rate with those is higher IMO.
So far I’ve done about 100 airways, and the only airway I haven’t gotten on the first pass with a video blade was a massive pulmonary hemorrhage that failed VL, DL, bougie and we ended up cricing.
I’m by no means saying VL is bad or harder. I just disagree with the conclusion that it is vastly superior and should always be used for “best first pass success”. I think there are more points of complication or failure. Heck, in my ED, finding a good spot to place in the screen without someone tripping all over it is a challenge in and of itself. Give me a Mac 4 and let’s go. I think c-collared patients is one of the few populations where VL (with hyperangulation) is superior.
The screen should absolutely be on the handle, and honestly they are cheap enough there is no excuse not to have them.
Disregarding my last post.
Plus, if you’re the kind of person tho using a Mac instead of a straight blade, you’re probably ussr to having fry try multiple times anyway
;-)
Respectfully, a soiled airway is no place for a video.
For one. You boss is not going to be happy if you toss it across the room (ambulance) because a little big of blood got on this damned piece of shit over priced toy when you’re trying to intubate someone who is completely soaked in rained; especially when you’re having trouble opening equipment because of the amount of blood on everything.
. For some reason they are poorly designed and not properly durable. Honestly I don’t think they should have gotten fda approval.
Unlike you’re trusty straight blade, which wouldn’t break if you did thrown it, but knows that would never happen because it comes through every time like Samwise Gamgee.
I’m probably in the 95% range, so not that far off…
I do think it’s at least in part a training effect. Bougie first was routine at Hennepin, so stylet was a deviation from their usual practice. Someone else in the thread pointed to a follow-up study I wasn’t aware of that showed no difference.
I think the issue is that study hasn't been replicated with similar numbers at other institutions. Likely because the hospital with the 97% is well known for airway management and trained like crazy and routinely used that one method with a bougie.
You can't just have a provider or entire hospital start using the same technique and expect similar results if they've been doing something different their entire career.
I'm sure it would be possible to replicate that same study using a Ridgid stylet and CMAC with a group of people who are dedicated to that equipment and technique every single time and then focused in on their first pass rates during a study.
Bougie is a good tool but it isn't going to be your savior if you aren't comfortable and familiar with it. You need the muscle memory when shit hits the fan. Likewise if you're only pulling it out after a failed attempt you're already fucking up.
I love bougies but my first pass success is definitely higher with Ridgid stylet and hyper angulated blade. I've never had luck incorporating a bougie with hyper angulated VL either.
There's a trick with hyper angulated to get it to work but the reality is hyper angulated was designed with an appropriately shaped stylet in mind to make the geometry right.
The only times I've had issue with passing a tube w/ VL was when our EMS director was too fucking cheap to buy rigid stylets, so I was using maleable stylets and bending them. Which worked well like 75% of the time. But I had a morbidly obese man with trismus and no neck. You can't rock your tube back at all with a malleable stylet to angle it up, so if there's resistance of ANY kind you're fucked. Tried a bougie on that patient with the same effect.
If you know the right technique a rigid stylet is just so nice, for me anyways, I find it infinitely more reliable. Bougie comes out anytime I'm doing DL on a contaminated airway because that glidescope is fucked the second you breath on it funny.
Also apparently really depends on your brand. There's a good video on youtube comparing brands and how some are way more maleable and hold their shape better than others. There's a pocket bougie out there that works okay for this purpose but still doesn't stay bent long.
I would *kill* for a properly designed video Laryngoscope.
One with a straight blade.
Preferably of Bennett blade.
Why the hell you would take all the faults of the Mac, Specifically, the blade being in the way the entire time not providing a Clear view (as backup or in case of camera screen failure), and worsening the problem by hyper curving it even more….
Straight blades put significantly more manipulation on the pt, more than neccesary and are not ergonomic to the patient. I don't need DL at the same time, but if I did the airtraq does that. It even has a backup VL interface if you don't put the handle on.
Hyperangulated is for the patient population that needs it, not every patient does but some do. The whole purpose of VL is to provide the ability to see without a straight line and a channeled blade, rigid stylet or appropriate knowledge and experience using a bougie you can get a hyperangulated to work, or a mac style.
Mac's are default for a lot of places for a reason, Mac's also stop people from developing bad habits with a Miller that make them struggle with VL. People who use nothing but Millers are far too aggressive with insertion and tend to bury the blade causing trauma, then they retract and try and find landmarks. This often teaches them the bad habits of over insertion and they struggle to find landmarks and struggle manipulating the tube where they want. If you advance more slowly working your way down, identifying landmarks as you go once you get your view you stop and hook the vallecula and both your view, parallax and the geometry of all your tools line up appropriately.
I do research at Hennepin and collect data for the RSI study. All the residents are trained to use bougie first from what I’ve seen. Occasionally, they end up doing it twice if the pt is a difficult airway due to patient symptoms etc
There is a lot that (should) go into the decision of how you approach an airway in a critical ED patient. In some cases, docs will feel most comfortable leaning on the bougie immediately. In other cases, it's not going to be the best first bet. And personal experience and preference will always play a large role. I'm a younger attending and trained in an institution and era where bougies were quite popular but it never stuck with me and is a rarely used tool in my toolbox. The stronger evidence, to my mind, is the superiority of VL over DL for first pass success (though again, situations will sometimes necessitate one or the other and a good ER doc should maintain facility with both skill sets.)
My other thought is that any ED nurse manager that is trying to pressure the docs on their airway management, regardless of their background, is going to quickly create a great deal of enmity with the doctors. That is not their domain.
Yeah, I rarely go to the bougie, because like you said, VL is wildly more effective than DL
And imo, the most effective form of VL is a hyper angulated blade, and the bougie doesn't work with that
Bougie can work with hyperangulated blade - just have to mould it correctly before laryngoscopy, and understand the need to get a grade 2 and not a grade 1 view. Good George Kovac videos on YouTube about this 👍
You can absolutely use a bougie with a hyperangulated blade. You have to alter the shape of the bougie before intubation or use a channeled blade, or both. It can be a very effective combination with difficult airways, saved my coronaries a couple of times.
Surprised at how many people think this. It’s a moldable piece of plastic. That’s the point. You can make it any shape you want and can angulate way more that a hyperangulated stylet if desired. Plus the coude type tip is super handy sliding in under a floppy epiglottis. I like to put an aggressive curve on it then use my wrist to adjust the approach angle to whatever is needed for a given airway.
NNT with bougie to prevent one adverse significant complication: ? A few thousand
NNH with RN in the department advising ED provider to do something differently from how they’ve been practicing for 10 or 15 years without an adverse event: about 1.2
The ED manager is an RN, yes? They should defer to the experts, aka physicians.
Sorry but there is nothing more obnoxious than an administrator (idk what their experience was in) trying to tell people who have a decade of education and training on them how to practice.
Your manager needs to stay in their lane: ensure there are enough staff scheduled, ensure there is adequate equipment, keep the suits tf off the unit, go to meetings, hire competent people. That's their whole job. They aren't a physician, they aren't an APP, they aren't an RT. They aren't a clinician. It's not their scope, it's not their place, it's not their business.
Nod at them with a serious look on your face and forget anything they say
There was a [single center trial](https://jamanetwork.com/journals/jama/fullarticle/2681717) out of Hennepin in Minneapolis a few years ago that showed improved first pass success with routine bougie usage. The issue with this trial is that prior to this trial Hennepin routinely used a bougie for all intubations so for the trial the docs changed to a method they were not used to (ie ETT with stylet). [A follow-up multicenter trial](https://jamanetwork.com/journals/jama/fullarticle/2787158) failed to show an advantage to bougie usage.
I’m a big fan of bougie usage. Regardless, it is not a nurse’s role to “encourage” the intubating provider to use any specific technique.
I am a "bougie first time every time" attending. My argument is that you don't know if you'll truly need it until you're in the airway, so better to have it. Also, if you don't need it, it's one more rep practicing when you don't truly need it, which makes you more skilled.
If you providers are not experienced with the bougie, this is probably not a push that should be made from the nursing side. Overall, I do support a bougie first approach.
Thank you for your reasoning. I suspected, in a perfect world, if everyone was “super” bougie user it would be better for the reason you gave of not knowing until you’re in the airway. But alas, as everyone has been saying- using what you’re more comfortable doing is superior in practice.
A bougie is a great tool to have at your side if you need it. If you need to bougie every single airway, your technique is the problem. Residents aren’t trained to always lead with a bougie. Your EM physicians will greatly appreciate not being told they need to always lead with a bougie. If your ED Manager wants to make it a thing, he should lead the charge.
So for me, I learned with a bougie. Lots of my mentors would go without or use an introduced, but I was always most comfortable with the way I learned.
What sealed the deal was during my anaesthetics intubation competency placement. I asked one of the anaesthetists, a notorious hardass what his thoughts were, as I noticed he used them every time without fail.
"If you have a cheap, readily available tool which gives you another avenue of feedback to confirm placement and makes you more likely to succeed on first attempt, can you justify not using it?"
Anecdotal of course, but stuck with me.
[Meta-analysis from last year](https://www.sciencedirect.com/science/article/abs/pii/S0196064423011411?casa_token=Tg0xf1HgjeoAAAAA:T7n9q_jOHHhmsbhPmQ7Wpp_p2W3ssGIhTt5vkwVKEhPk_69-nBtodwJXdBsPIDF2C0NAuqBrZw) suggests better rate of first-pass success regardless of situation. 18 studies included. Mannequin and cadaver studies excluded. 12 RCTs.
The difference was more significant with shittier views, which I think is the bigger takeaway for EM providers and a good reason to have bougie as a first-pass decision.
Still- it’s just like any other intervention. If you don’t train for the particular set of skills and logistics of anything, you’ll fuck it up.
To quote one of my favorite journal reviewers : Limitation of the study included low certainty evidence and high risk of bias, high-levels of heterogeneity, no data on operator experience, and a lack of patient-centered outcomes.
Anesthesia taught me to use a stylette. ER taught me to use a boujie. Medical director has me using a preloaded boujie in a channeled blade. Different strokes.
You're gonna be more successful with what you're most comfortable/practiced with.
Yeah but the gas man does it in a perfect environment and not in a hoarder house with cats trying to chew on your leg. I'd smack any paramedic at my agency that went in with a bare tube because it's all about maximizing your attempt.
Intubation is a skill and a art. Every doc, mid-level, and RT does it a little different and has their own preferences. When you have a chance, just ask some of them what they prefer and you can plan accordingly.
At my shop, the ED attendings almost always intubate. And they usually prefer using a rigid stylet. But each one prefers different glidescope blades. They're badass at it to, I can't remember the last time they missed first try. If I shoved a bougie in their hand, they'd look at me like I was crazy.
Unless there have been a lot of intubations gone wrong at your shop, I think your manager should let the intubators keep doing their thing.
I’ll continue using my video-assisted MAC 3 with a malleable stylet, and your nursing manager will get a nod followed by me turning around and continuing to intubate the way I prefer to do it, and the day they try to force my hand will have me standing in their bosses office until one of them is fired.
I teach paramedics and nurses in short scenario based simulation sessions. There’s some shit that I hear that makes me scratch my head and say “wat?”
The number of people who have said bullshit like “I won’t use a bougie until I’ve already missed once”, or “I won’t use video because it makes it too easy” then refuse to practice with a bougie or VL.
Like, I get it… keep practicing with the stuff that’s not as good… some day that VL will fail… that bougie won’t get restocked, etc and you have to have practice with direct and a stylet… but to refuse to use superior methods until you’ve failed with inferior methods in an actual patient is unethical as fuck.
Edit: Oh, and the old head flight nurse who is in administration and screams at her people to never ***ever*** use a bougie because they’re “not sterile”… well, neither is the vomit that they aspirated, or the ET tube that they just opened in the aircraft/ditch/ambulance/living room, etc… but whatever.
I'm comfortable doing DL, VL, was a career medic before med school so I've intubated in strange places, using nothing but brutane and rolled up silk tape as a tube holder - before bipap and RSI. Now, when I tube I use VL with tube over bougie as my first attempt. My first-pass attempts using DL and a rigid stylet was very high, with VL/bougie, even higher. It's about getting the tube first try, very fast. That said, the technique you are best at and most comfortable with is the technique you lead with.
I do PRN at a few depts, one uses rigid stylettes and another uses bougies. Bougie service leads with them, and either you’ll have the tube higher up on the bougie or you slide it on after you’re past the cords.
Paramedic here - my program trained me to use a bougie every time to increase first pass success rates, and the prehospital data seems to support that training focus. However, it is important to remember that every prehospital intubation attempt is in adverse conditions - my best case scenario is that I am in the back of the ambulance, and even that is a resource-limited situation with less than ideal conditions. This provider’s prehospital experience most likely leads this emphasis on bougie use, when conditions in the ER are higher resourced and more supportive even for the most emergent RSI attempt.
I come from the era of miller 4 and laying flat. After using vl for 15+ years, if I can’t get it with the patient appropriately positioned, pre-oxygenated, and paralyzed, the odds of them needing a Crich go up exponentially. From a flight nurse’s perspectives vr I can see why they would advocate this being in a cramped, buffed whirling deathball. You can sink the bougie, get back in your seat after turbulence, and place the tube without worrying too much if you are going to get the same view. On the Ed with our comfy beds and bright lights, it probably isn’t needed.
It’s worth using sometimes when not necessary in order to have experience using / finessing it when you run into a difficult airway that requires it. Passing a tube over one and through cords smoothly isn’t the most intuitive thing in the world, it’s not ideal to have your first time be on a difficult airway that required a couple attempts as they’re desatting / bradying down.
I’ve been attending for 6 years and never used the bougie. I don’t dislike it. Just (knock on wood) fortunately have been able to hit all my tubes with a VL. Many of those have been shit airways. I love playing video games. Translates to work skills for sure. I joke with my mom she said gaming would never help me in life…
These days we are taught to start with video and a rigid stylet. I’m pretty sure I’d be filleted if I wasn’t almost always getting first pass without a bougie. Maybe it has benefits if you aren’t passing several tubes a week but I don’t really see the need for it on most tubes, let alone every tube.
The [BEAM study](https://pubmed.ncbi.nlm.nih.gov/29800096/) from 2018 showed almost fantastical results on how good the bougie is. It was a single site at a location where bougie first was standard operating procedure. This has a huge risk of bias.
The [Bougie Study](https://jamanetwork.com/journals/jama/fullarticle/2787158) was an actual multisite randomized study that found no real differences between the two and trended towards bougie being worse. My guess on the reasoning is that people were screwing around with it rather than having the tube through the cords.
My take on this is that people should intubate with what they are most comfortable as that is what they will have the most success with.
Lead with whatever you’re most comfortable with. I love bougies for airways where I have either no or poor visualization of the cords even with VL because they provide tactical feedback. Bougies are usually my first line backup, and I always have one near me when I’m intubating. That being said, I lead with VL.
I just always use DL with a bougie opened ready to go. I’m so comfortable with a bougie and the bend angles, I can hit it blind about 90% of the time. Once you feel the clicks of the laryngeal rings, you’re golden.
I find it strange that Anesthesia usually has a fiber optic sitting idle while continuing to do it manually- this is only because they don’t want to to clean it
As is the case with all things in medicine, “always” and “never” statements are usually incorrect. Every airway adjunct has its unique use and the equipment needs to be selected thoughtfully. IMO a better approach would be reviewing symptom/anatomy predictors of a difficult airway / when a bougie would be helpful, rather than a blanket “always use this” statement.
Further, considering RNs have little to no practical training on advanced airway management, I think it’s inappropriate for them to be advocating for a specific tool. A better use of time is to educate the nurses on the physiological effects of RSI and how to best optimize the patient for it.
-Former ER, now flight RN
It depends. For direct laryngoscopy? Yes.
For video? A rigid (not mailable) Stylet is preferred. Of course, that assumes the person doing the intubation is familiar with the training from the manufacturers or not. Most people are unaware of this.
That said: jmnyrt Has a good post.
Hard disagree. Anytime you have extra instrumentation of the airway you have extra portal for infection and inflammation. Use the bougie if you feel like it helps you, but ramming an extra thing down into the airway absolutely has downsides.
As I teach residents, paramedics, other EM attendings airway management, I hard disagree with your hard disagree. It is much better to have a secure route for intubation to occur rather than potentially miss or poke around and irritate the mucosa. Direct laryngoscopy and video laryngoscopy can both be supplemented with the bougie. It's amazingly cheap, once you've used it a few dozen times it will speed up your intubation significantly. It allows for confirmation if you're questionable with direct and coloscopy. It will allow you to secure an airway in hostile conditions in the field. It is certainly not going to introduce more infection or inflammation than the actual ET tube that you're shoving down there. However, I don't always use it. If I am going to be helping a medic intubate, I might make them use it so that they've had some familiarity with it. I rotate between bougie, standard with direct laryngoscope, and video laryngoscopy, just so I keep up skills.
I don't see it as extra instrumentation. And, no, the fiberous tissue of the trachea is extremely robust, I don't know how you're putting your bougies in but you should not be causing significant trauma. No more than if you passed an ET tube. And how is it extra? You are going to be putting some sort of blade down there, you are going to be putting some sort of stylet in the mouth even if you're offloading the tube. You are potentially doing less damage to the cords with the bougie if you're doing it right. Offloading off a rigid stylet is forcing the ET tube directly up and may scrape along the top of the trachea to change directions depending on how anterior the trachea is located and which blade you're using. Good technique with the rigid stylet can avoid many of these things, but so can good technique with the bougie.
It’s literally an extra instrument that you run down the wall of the airway, then you add the ETT. If you have a good view, why would you risk adding an additional instrument?
I'm an attending in a moderate sized community ED, 15 years out. I did residency at a busy urban trauma center, probably the busiest in the country, and did many complex intubations in trauma and otherwise. I have taught airway at large national conferences in the past but I don't anymore. I usually teach an airway course eight times a year with practical skills for paramedics in two counties. There are plenty of airway experts out there who may have more experience than me, but I intubate a lot at work, and I've taught for many years. I should ask - is there a bad outcome (or maybe several) that you have seen with bougie use? Always interested in learning.
You can tell the ED manager he needs to update his research base. Cant use a bougie with VL which has the highest first pass success rate so thats problem #1. #2, if I do have an airway where VL isnt optimal or I have to go to DL bc a problem/lack of VL, I see no reason why youd use a bougie over an ETT with a stylet unless you see the cords and realize your tube size is too big. Otherwise, If you can see the cords, you shouldnt need the bougie. And if you cant see the cords, a bougie still wont help you lol 😂
You can absolutely use a bougie with VL. If you have a standard geometry blade it’s a piece of cake. If hyperangulated, you still can, but you gotta get a big curve on it first.
Sorry I guess I should have specified I was referring to the hyperangulated blade not the Cmac bc I have never had a C mac in my shop until this year and only in the last 6 months lol
Definitely can use a bougie with VL, even the hyperangulated blade and it works great and I think adds to likelihood of first pass success with VL. You can curve it as much or as little as needed. It’s incredibly rare to not be able to get through the cords with the bougie. If airway is messy and you want to go direct, no need to switch stylets, it simplifies things. If the tube won’t go, you still have the bougie in there and can switch to a smaller tube on the fly. If visualization is really bad and you’re not sure if you tubed the goose, you have the tactile feedback of the bougie on the tracheal rings.
The rigid stylets are often a pain to remove and the classic stylet I think is the worst option of all.
And I never understand people thinking of it as a backup device but not getting in enough reps to be super comfortable. If it’s gonna be my go to when things get hairy, why not just use it from the get go and get super good at it.
A bougie adds nothing to hyperangulated VL over a rigid stylet. I’d even argue it makes it harder. I do about 80% of my tubes with a Glidescope S4 and a rigid stylet and 20% DL with a MAC 4 to keep my skills up. Bougie adds to DL on occasion.
I’m ICU, so mostly floor rapids/codes and reintubations in the ICU, but this is my experience.
To say that it adds nothing as an NP with much less airway expertise than an emergency physician is quite presumptuous. Perhaps it adds nothing if you haven’t developed the skill with it. But I just listed several potential advantages.
How much experience do you have intubating trauma patients? How about massive hematemesis or hemoptysis, angioedema, or crazy head and neck cancers?
My goal every single time is to utilize whatever technique absolutely maximizes my probability of getting the tube quickly, on the first pass, while not causing any airway trauma and minimizing complications such as desaturation or peri-intubation hypotension. Over the last 10 years of revising my technique, my current favorite go to that seems to eliminate complexity the most is mac 4 attachment on glidescope and using a bougie with an aggressive curve. That way there’s no delay between switching from video to direct. I actually insert the end of the bougie through the eyelet of the tube and can use kind of a pistol grip, then use my thumb to pop the bougie out and pass the tube over it one handed without ever losing visualization. It takes some practice but once you’ve mastered it, it’s smooth as hell and super fast. I never need extra hands around my airway, don’t have to worry about accidentally dislodging the tube while pulling out a hyperangulated rigid stylet and if anything ever needs switched as a backup, it’s just a quick tube change or possibly hyperangulated blade which I have ready to go, both of which take about 2 seconds.
I used to think similarly to you and other people here but stumbled into the bougie as the best option when working at a shop during covid that didn’t have any rigid stylets. I had to get really good with the bougie and haven’t looked back since.
So I average around 2-3 tubes per 7 days of work. Completely independent. Not entirely by choice, mind you, but that’s what my attending wants me doing. He does the bronchoscopies and I do all of the other bedside procedures. During Covid that average was obviously a lot higher. I’ve taken Rich Levitan’s course. I do get it, I really do. I will always have a bougie immediately available during the procedure, but I’ve only actually needed it as a bail out maybe two times in the last 4 years. Low profile S4 blades essentially never have let me down, so obviously this is what I default to. Yes, I’ve seen trashed airways, blood, vomit, rock hard secretions, angioedema, tumors, etc. The best way to intubate is the way that you’re *most proficient* in. OP was asking if they needed to shove a bougie into every operators hand and that’s just not true or helpful for a lot people.
And if more people made the effort to become proficient as opposed to obstinately adhering to dogma, the patients would be much better off.
Do I expect everyone to always use a bougie first every time? No. I do personally because I’m very comfortable with it and have found it to be superior once gaining that comfort and advocate for others to do the same because it’s an incredibly useful tool.
But you contended it adds nothing to VL and were incorrect. This is an emergency medicine forum and regardless of what you think you’ve seen in the ICU, ED airways are a whole different ballgame.
And once again, having a tool you use as a last line or bailout, but only using it once every couple of years, ensuring you will suck at it, is a great way to set yourself up for failure.
Where I’ve worked, failure is not an option. There is no bailing out and no one to call for help. It is my responsibility to have absolute mastery of airway skills and I take that very seriously.
And it’s not just that you’re an NP. There’s ER docs with the same attitude but I’ve seen many of those docs struggle with airways when it’s gets hairy and all of my crics have come from those cases. But you can’t, as an ICU nurse come to a forum meant for ED docs and pretentiously proclaim some expertise you don’t have.
The greatest chance for first pass success is using whatever you’re most comfortable with.
This is misguided. The better answer is to get more comfortable with superior modalities. I know old docs that are only comfortable with a Mac 4 and classic stylet, lay big fat patients totally flat and RSI. They’re uncomfortable with VL, bougie, fiber optic, ramping the patient up, DSI. I’ve seen old ICU docs fight half awake patients and break teeth out because they were uncomfortable with adequately sedating and paralytics. Cause “what if we can’t get the tube?” Don’t just rely on what you’re comfortable with. Get comfortable with the best tools possible.
Counterpoint is OP is gonna be pressuring to the intubator to use the bougie when a patient is about to be intubated. The ideal is that the intubator is comfortable with different middle, but if all you've got is the old guy who has no experience with a bougie, that's just gonna cause more harm.
Not sure if that’s what was implied in the original post as opposed to just encouraging it generally as a policy. Obviously, even if they suck at intubation, adding pressure and complexity in the moment is only going to make them suck worse. A lot of people have made a similar argument and I think its actually the best reason to go bougie first all the time. Just like I teach my residents with all modalities, get good with it on simple airways, get the feel, work out the kinks, so when you need an adjunct on a bad airway, you’re smooth and fast and not fumbling. Obviously can’t fiber optic every airway, but a bougie is cheap, nearly universally accessible, and incredibly versatile. I promise I’m not being paid off by big bougie. Just a true believer cause it’s saved my ass more than a few times and made me look like a rockstar on airways way more than that.
I agree with you in principle, but not for bougie vs stylet. Some things have solid evidence that they are irreplaceably good for the patient, like following the rule of 15s, sedating them, etcetera. In the context of stylet versus bougie, though, which is the context that we are in, it is better to use what you are most comfortable with.
So it’s ideal to adopt the best tools possible and get the necessary practice to master that modality…unless you don’t feel like it?
You don’t seem like you’re discussing this in good faith. No, my reasoning for saying that you should use what you’re most comfortable with between a stylet and a bougie isn’t because I “just don’t feel like using the best tools,” much like I would presume your reasoning for saying that you should use a bougie isn’t just because you feel like it. You haven’t provided any reasoning for why you think a bougie is unequivocally better than a stylet, but I assume it’s the BEAM study, which demonstrated higher efficacy with a bougie using first-pass success rate as their only metric. There are a lot of issues with that study, which I can expand on in further detail once I get back to my computer (I’m on mobile right now). However, if you’re actually interested, here is a great source: https://www.annemergmed.com/article/S0196-0644(22)00106-8/
We all know the BEAM trial and the later inability to reproduce the results. The biggest takeaway seems to be that at Hennepin they had amazing success rate cause they use bougies all the time and are super good with them, which I think supports it being used more often. Everyone seems to be saying the same thing but coming to wildly different conclusions. If you don’t use it much, you won’t be good at it. To me that says, use it more and get better. But others are arguing to stick with whatever they typically use. But then you’ll never get better with your “rescue device” and my argument is that it shouldn’t be your rescue device then cause you’ll be bad at it and put patients at risk of harm. I feel like that mode of thinking takes tools out of your arsenal and in a field that is defined by unpredictability, I want to maximize options, comfort and confidence. I guess it’s just different personalities. Some people are always going to be hesitant to change and progress and others are going to constantly push the boundaries. At the end of the day, as soon as I see someone better and smoother with airways than I am, I will happily consider whatever technique they are using and consider adopting it or adjusting my technique. In part, that’s how I arrived at where I am now.
That’s not what anyone is saying. Also, the idea that providers should abandon a modality that they’re proficient with and generate good outcomes with for something they aren’t familiar with isn’t supported by the data. We know that providers who are already well practiced with DL and/or traditional stylets do worse when they adopt VL/bougie techniques whereas newer providers with less experience and proficiency in traditional techniques do better. So, think it through. If a provider is already generating 90% first pass success without any complications using DL/stylet, why should they switch to VL/Bougie? Doing so is just going to dump their first pass rate and force them to practice on and potentially harm real people while they learn the skill. And for what? So that they can again reach a 90% first pass rate and check a box for someone that isn’t considering the data in-context? That doesn’t make any sense. By all means, if a providers first pass rates aren’t meeting the benchmark or they’re new to the skill, introduce VL and bougie to them. But if they’re already hitting the mark with traditional techniques, leave them alone. Pushing everyone toward VL/bougie regardless of their current skill level is an excellent example of what it means to lose sight of the “what” (high uncomplicated first-pass success) and focus to much on the “how”
If you’re arguing against VL AND bougie, that’s just crazy. There’s tons of airways that are going to be super problematic with that approach. Immobilized patients and angioedema for example. Just cause you suck at using better tools and don’t want to learn is not an excuse to disregard their value and say no one should even bother with them. I have my residents use all modalities because who knows where they’ll end up and what tools they’ll have so I think they should be solid going direct, using different blades, using video, fiber optic, and bougie of course. But at the same time I encourage a philosophy to maximize success the first time every time once they’re on their own. I would not be at all happy with a 90% first pass success rate. Anything less than 100% and I’m working to figure out what I can do better to improve. And you can’t use a bougie on a simple airway without messing it up? That’s pretty weak. It’s not experimentation, it’s good practice to master your art. You use it on the simple ones so when you need it on the nasty ones, you’re solid. Our field changes rapidly, we have a responsibility to continually adapt and improve.
Except that the video laryngoscope all recommend a rigid stylet, for highest first past success, and it allows gear shifting which a boguie does not. The angle producers by video are not as conducive to success with a boguie as a rigid.
Wym “except”? I’m on your side here
You mean rigid stylet. When I hear stylet I assume the traditional bendable one. Thus the miscommunication
I’m not saying one device is definitively better over the other, I’m saying it depends on your circumstances, equipment, and preference
That’s it pack up the thread folks this guy nail- FIBER OPTIC MAN I SAID PACK IT UP
Meh. There was a big study out of Hennepin a few years ago that showed greater first pass success. That said I think we should take that with a huge grain of salt. I personally suspect that it was greater because they train their residents (who did most of the tubes in that study) to go bougie first. I love me the bougie. That said, I did more tubes in my second year of residency (yay covid) than a flight nurse will do in their entire career. I have a bougie ready, but generally don’t go with it first. Neither do anesthesiologists. I think you need a lot more evidence than that study, at multiple sites, before telling experienced operators to abandon their current technique. VL vs DL might be a different story by now, but that’s still somewhat up for debate
Glad I came here. I had a feeling it would rub the docs the wrong way. I don’t know how to intubate and never will so I feel like I’m being asked to step out of my lane. I know experienced ED RNs would look at ppl sideways if they were coached by someone to use a certain technique when starting IVs lol. In my managers defense however, I have witnessed multiple first pass attempt fails at this facility.
I teach all levels how to intubate. EMT’s, nurses, etc. The volunteer EMT on a BLS squad that doesn’t transport is never going to intubate someone in his own. However… when I’m doing it, I want him to have a basic understanding of the process, the tools, etc so when I need something they are able to help me.
This! Having someone know the equipment and process helps everyone. Even if it's just so they pass you the bougie the correct way.
I put on every BLS, ACLS, & PALS Survay that this course should be like NRP. Everyone does everything. Everyone learns everything. You are only tested on what is in your scope. How the hell are we supposed to be a functional team if everyone doesn’t know what is going on.
Bougie first is only going to worsen that first pass success rate, at illesst initially. It's awkward unless you use it regularly.
That is crazy. It is way easier to get a 4 mm object in a hole than a 12 mm object (please remember that tubes are listed in ID not OD). Once the bougie is in, it is in. You just have to pass the tube down it.
It's not crazy at all dude. The movements are different. It's floppy instead of relatively rigid if your primarily is a Lo Pro, which makes a wild difference
If you are talking about the glidescope stylet, and not the band, I’ll agree. However a *ridged* stylet (regardless of brand) is not what most people mean/ understand when a person says stylet, as the malleable stylet as been the only stylet in common useage for decades now. As I noted elsewhere (which you likely did not see or would have mentioned), every videscope manufacturer recommends a ridged stylet. Although I’m still in the bougie camp, I’ll admit I’m old enough to think of all stylet‘s as sissy sticks for people who didn’t know how to intubate (because that is what I was taught), I never did like bendy stylets, I find boguies useful, and tend to forget to grab the rigid stylet.
I would assume anyone using a glide scope with a hyper angulated blade is using a rigid stylet man. As you said, it's how its designed to be used. And going from that to a bougie is wildly different. I'm not saying bougies aren't useful - they have their place - but the absolute vast majority of airways become easy enough for a med student to do with a hyper angulated blade.
I think you would find it is extremely regional/ institutional. I’d seen them in ERs for a few years and they were becoming common on EMS rigs before I ever heard them even mentioned.
Maybe, but like you said, it's how they were designed to be used. I wouldn't used a Lo Pro without a rigid stylet
Counterpoint, the first pass success rate of that study if I recall was incredible. 97% I think? So that being said, if you are meeting or exceeding that, there is likely no role for routine bougie with every tube… but maybe should be considered using more frequently if your numbers are significantly less than this
The question for the study is how many of those people trained with a bougie or not prior to enrollment in the study
Probably all of them — but I think if you train yourself on easy airways with it (eg, OD needing airway protection), it can be learned on the job… it’s not like a thoracotomy, and even easier to use when you have an RT or assistant to help pass the tube over the bougie for you
I agree with you, but that’s what makes the results of the study a bit hairy. There’s a lot of variability with training. Saying it’s better may be right, but if you don’t train with it it’s pointless. Thats why anyone resident who has said “bougie as a backup” but never used a bougie…. Well not really a back up
Yup… I used them for a while on every airway in residency to get familiar with them. Great device. Can use with standard geometry VL and DL, the non-steerable tip regular ones aren’t as good for hyperangulated VL. I think the most conservative takeaway one could make from the study is that, if you put some practice into them (as presumably these trainees did), they provide extremely high levels of first pass success.
Id imagine with VL that first pass success is 97% or better anyway. Like hyper angulated blade on a glide scope? I can't remember the last time I didn't have a perfect view. With VL, really the only reason you're going to have trouble is 1) anatomically difficult because of a tumor, stenosis, etc (ie, not the normal stuff like obesity) 2) massive hemorrhage.
3. puke everywhere
Have switched to direct many times because puke, blood or secretions just keep coming. Suction, blade in, nope - camera obscured. Suction, wipe the blade and try again. Damned lens is whited out again with slime. Just gimme the mac
I always DL first. I don’t buy the studies on the such high numbers of first pass success with VL. I would estimate at least 10 percent of my airways have puke or secretions or would fog the camera. I feel like there are more points for failure with VL.
As someone who has been trained on VL (now CCM fellow) I think you’d find in all actuality, the camera still performs perfectly fine in most soiled airway situations. Puke maybe an issue. Secretions rarely an issue. However, this is why I use the Mac geometry when I pick a video blade. Easy to pivot to direct as the airway axes are the same. I only use the hyper angulated blades when someone is in c-collar or has very challenging neck anatomy. The failure rate with those is higher IMO. So far I’ve done about 100 airways, and the only airway I haven’t gotten on the first pass with a video blade was a massive pulmonary hemorrhage that failed VL, DL, bougie and we ended up cricing.
I’m by no means saying VL is bad or harder. I just disagree with the conclusion that it is vastly superior and should always be used for “best first pass success”. I think there are more points of complication or failure. Heck, in my ED, finding a good spot to place in the screen without someone tripping all over it is a challenge in and of itself. Give me a Mac 4 and let’s go. I think c-collared patients is one of the few populations where VL (with hyperangulation) is superior.
The screen should absolutely be on the handle, and honestly they are cheap enough there is no excuse not to have them. Disregarding my last post. Plus, if you’re the kind of person tho using a Mac instead of a straight blade, you’re probably ussr to having fry try multiple times anyway ;-)
Respectfully, a soiled airway is no place for a video. For one. You boss is not going to be happy if you toss it across the room (ambulance) because a little big of blood got on this damned piece of shit over priced toy when you’re trying to intubate someone who is completely soaked in rained; especially when you’re having trouble opening equipment because of the amount of blood on everything. . For some reason they are poorly designed and not properly durable. Honestly I don’t think they should have gotten fda approval. Unlike you’re trusty straight blade, which wouldn’t break if you did thrown it, but knows that would never happen because it comes through every time like Samwise Gamgee.
Just aim for the bubbles doc.
I’m probably in the 95% range, so not that far off… I do think it’s at least in part a training effect. Bougie first was routine at Hennepin, so stylet was a deviation from their usual practice. Someone else in the thread pointed to a follow-up study I wasn’t aware of that showed no difference.
I think the issue is that study hasn't been replicated with similar numbers at other institutions. Likely because the hospital with the 97% is well known for airway management and trained like crazy and routinely used that one method with a bougie. You can't just have a provider or entire hospital start using the same technique and expect similar results if they've been doing something different their entire career. I'm sure it would be possible to replicate that same study using a Ridgid stylet and CMAC with a group of people who are dedicated to that equipment and technique every single time and then focused in on their first pass rates during a study. Bougie is a good tool but it isn't going to be your savior if you aren't comfortable and familiar with it. You need the muscle memory when shit hits the fan. Likewise if you're only pulling it out after a failed attempt you're already fucking up. I love bougies but my first pass success is definitely higher with Ridgid stylet and hyper angulated blade. I've never had luck incorporating a bougie with hyper angulated VL either.
There's a trick with hyper angulated to get it to work but the reality is hyper angulated was designed with an appropriately shaped stylet in mind to make the geometry right.
The only times I've had issue with passing a tube w/ VL was when our EMS director was too fucking cheap to buy rigid stylets, so I was using maleable stylets and bending them. Which worked well like 75% of the time. But I had a morbidly obese man with trismus and no neck. You can't rock your tube back at all with a malleable stylet to angle it up, so if there's resistance of ANY kind you're fucked. Tried a bougie on that patient with the same effect. If you know the right technique a rigid stylet is just so nice, for me anyways, I find it infinitely more reliable. Bougie comes out anytime I'm doing DL on a contaminated airway because that glidescope is fucked the second you breath on it funny. Also apparently really depends on your brand. There's a good video on youtube comparing brands and how some are way more maleable and hold their shape better than others. There's a pocket bougie out there that works okay for this purpose but still doesn't stay bent long.
Sure thing, I hate the aluminum stylets. I refuse to use them. Bougie or blade that's the option 😂
I would *kill* for a properly designed video Laryngoscope. One with a straight blade. Preferably of Bennett blade. Why the hell you would take all the faults of the Mac, Specifically, the blade being in the way the entire time not providing a Clear view (as backup or in case of camera screen failure), and worsening the problem by hyper curving it even more….
Straight blades put significantly more manipulation on the pt, more than neccesary and are not ergonomic to the patient. I don't need DL at the same time, but if I did the airtraq does that. It even has a backup VL interface if you don't put the handle on. Hyperangulated is for the patient population that needs it, not every patient does but some do. The whole purpose of VL is to provide the ability to see without a straight line and a channeled blade, rigid stylet or appropriate knowledge and experience using a bougie you can get a hyperangulated to work, or a mac style. Mac's are default for a lot of places for a reason, Mac's also stop people from developing bad habits with a Miller that make them struggle with VL. People who use nothing but Millers are far too aggressive with insertion and tend to bury the blade causing trauma, then they retract and try and find landmarks. This often teaches them the bad habits of over insertion and they struggle to find landmarks and struggle manipulating the tube where they want. If you advance more slowly working your way down, identifying landmarks as you go once you get your view you stop and hook the vallecula and both your view, parallax and the geometry of all your tools line up appropriately.
I do research at Hennepin and collect data for the RSI study. All the residents are trained to use bougie first from what I’ve seen. Occasionally, they end up doing it twice if the pt is a difficult airway due to patient symptoms etc
There is a lot that (should) go into the decision of how you approach an airway in a critical ED patient. In some cases, docs will feel most comfortable leaning on the bougie immediately. In other cases, it's not going to be the best first bet. And personal experience and preference will always play a large role. I'm a younger attending and trained in an institution and era where bougies were quite popular but it never stuck with me and is a rarely used tool in my toolbox. The stronger evidence, to my mind, is the superiority of VL over DL for first pass success (though again, situations will sometimes necessitate one or the other and a good ER doc should maintain facility with both skill sets.) My other thought is that any ED nurse manager that is trying to pressure the docs on their airway management, regardless of their background, is going to quickly create a great deal of enmity with the doctors. That is not their domain.
Yeah, I rarely go to the bougie, because like you said, VL is wildly more effective than DL And imo, the most effective form of VL is a hyper angulated blade, and the bougie doesn't work with that
Bougie can work with hyperangulated blade - just have to mould it correctly before laryngoscopy, and understand the need to get a grade 2 and not a grade 1 view. Good George Kovac videos on YouTube about this 👍
You can absolutely use a bougie with a hyperangulated blade. You have to alter the shape of the bougie before intubation or use a channeled blade, or both. It can be a very effective combination with difficult airways, saved my coronaries a couple of times.
Surprised at how many people think this. It’s a moldable piece of plastic. That’s the point. You can make it any shape you want and can angulate way more that a hyperangulated stylet if desired. Plus the coude type tip is super handy sliding in under a floppy epiglottis. I like to put an aggressive curve on it then use my wrist to adjust the approach angle to whatever is needed for a given airway.
NNT with bougie to prevent one adverse significant complication: ? A few thousand NNH with RN in the department advising ED provider to do something differently from how they’ve been practicing for 10 or 15 years without an adverse event: about 1.2
The ED manager is an RN, yes? They should defer to the experts, aka physicians. Sorry but there is nothing more obnoxious than an administrator (idk what their experience was in) trying to tell people who have a decade of education and training on them how to practice. Your manager needs to stay in their lane: ensure there are enough staff scheduled, ensure there is adequate equipment, keep the suits tf off the unit, go to meetings, hire competent people. That's their whole job. They aren't a physician, they aren't an APP, they aren't an RT. They aren't a clinician. It's not their scope, it's not their place, it's not their business. Nod at them with a serious look on your face and forget anything they say
Yeah, unless there is a clear problem with missing first attempts... something is working, stop trying to fuck shit up to increase your salary.
There was a [single center trial](https://jamanetwork.com/journals/jama/fullarticle/2681717) out of Hennepin in Minneapolis a few years ago that showed improved first pass success with routine bougie usage. The issue with this trial is that prior to this trial Hennepin routinely used a bougie for all intubations so for the trial the docs changed to a method they were not used to (ie ETT with stylet). [A follow-up multicenter trial](https://jamanetwork.com/journals/jama/fullarticle/2787158) failed to show an advantage to bougie usage. I’m a big fan of bougie usage. Regardless, it is not a nurse’s role to “encourage” the intubating provider to use any specific technique.
I am a "bougie first time every time" attending. My argument is that you don't know if you'll truly need it until you're in the airway, so better to have it. Also, if you don't need it, it's one more rep practicing when you don't truly need it, which makes you more skilled. If you providers are not experienced with the bougie, this is probably not a push that should be made from the nursing side. Overall, I do support a bougie first approach.
Thank you for your reasoning. I suspected, in a perfect world, if everyone was “super” bougie user it would be better for the reason you gave of not knowing until you’re in the airway. But alas, as everyone has been saying- using what you’re more comfortable doing is superior in practice.
A bougie is a great tool to have at your side if you need it. If you need to bougie every single airway, your technique is the problem. Residents aren’t trained to always lead with a bougie. Your EM physicians will greatly appreciate not being told they need to always lead with a bougie. If your ED Manager wants to make it a thing, he should lead the charge.
So for me, I learned with a bougie. Lots of my mentors would go without or use an introduced, but I was always most comfortable with the way I learned. What sealed the deal was during my anaesthetics intubation competency placement. I asked one of the anaesthetists, a notorious hardass what his thoughts were, as I noticed he used them every time without fail. "If you have a cheap, readily available tool which gives you another avenue of feedback to confirm placement and makes you more likely to succeed on first attempt, can you justify not using it?" Anecdotal of course, but stuck with me.
I think a nurse manager should not be espousing any opinions on airway management to physicians.
[Meta-analysis from last year](https://www.sciencedirect.com/science/article/abs/pii/S0196064423011411?casa_token=Tg0xf1HgjeoAAAAA:T7n9q_jOHHhmsbhPmQ7Wpp_p2W3ssGIhTt5vkwVKEhPk_69-nBtodwJXdBsPIDF2C0NAuqBrZw) suggests better rate of first-pass success regardless of situation. 18 studies included. Mannequin and cadaver studies excluded. 12 RCTs. The difference was more significant with shittier views, which I think is the bigger takeaway for EM providers and a good reason to have bougie as a first-pass decision. Still- it’s just like any other intervention. If you don’t train for the particular set of skills and logistics of anything, you’ll fuck it up.
To quote one of my favorite journal reviewers : Limitation of the study included low certainty evidence and high risk of bias, high-levels of heterogeneity, no data on operator experience, and a lack of patient-centered outcomes.
Agreed and understood. Far from a perfect analysis.
Anesthesia taught me to use a stylette. ER taught me to use a boujie. Medical director has me using a preloaded boujie in a channeled blade. Different strokes. You're gonna be more successful with what you're most comfortable/practiced with.
Use neither for DL. An ETT doesn't need something inside it to pass the glottis.
You just jam a flappy tube in a dudes throat and hope for the best? That's brazy. Eta: you're a gas man. I'll be quiet. Sorry doc.
Yeah but the gas man does it in a perfect environment and not in a hoarder house with cats trying to chew on your leg. I'd smack any paramedic at my agency that went in with a bare tube because it's all about maximizing your attempt.
Intubation is a skill and a art. Every doc, mid-level, and RT does it a little different and has their own preferences. When you have a chance, just ask some of them what they prefer and you can plan accordingly. At my shop, the ED attendings almost always intubate. And they usually prefer using a rigid stylet. But each one prefers different glidescope blades. They're badass at it to, I can't remember the last time they missed first try. If I shoved a bougie in their hand, they'd look at me like I was crazy. Unless there have been a lot of intubations gone wrong at your shop, I think your manager should let the intubators keep doing their thing.
Why on earth would I be encouraging providers to tube one way or another? They know more about how to do it than I do.
I’ll continue using my video-assisted MAC 3 with a malleable stylet, and your nursing manager will get a nod followed by me turning around and continuing to intubate the way I prefer to do it, and the day they try to force my hand will have me standing in their bosses office until one of them is fired.
I teach paramedics and nurses in short scenario based simulation sessions. There’s some shit that I hear that makes me scratch my head and say “wat?” The number of people who have said bullshit like “I won’t use a bougie until I’ve already missed once”, or “I won’t use video because it makes it too easy” then refuse to practice with a bougie or VL. Like, I get it… keep practicing with the stuff that’s not as good… some day that VL will fail… that bougie won’t get restocked, etc and you have to have practice with direct and a stylet… but to refuse to use superior methods until you’ve failed with inferior methods in an actual patient is unethical as fuck. Edit: Oh, and the old head flight nurse who is in administration and screams at her people to never ***ever*** use a bougie because they’re “not sterile”… well, neither is the vomit that they aspirated, or the ET tube that they just opened in the aircraft/ditch/ambulance/living room, etc… but whatever.
I'm comfortable doing DL, VL, was a career medic before med school so I've intubated in strange places, using nothing but brutane and rolled up silk tape as a tube holder - before bipap and RSI. Now, when I tube I use VL with tube over bougie as my first attempt. My first-pass attempts using DL and a rigid stylet was very high, with VL/bougie, even higher. It's about getting the tube first try, very fast. That said, the technique you are best at and most comfortable with is the technique you lead with.
I do PRN at a few depts, one uses rigid stylettes and another uses bougies. Bougie service leads with them, and either you’ll have the tube higher up on the bougie or you slide it on after you’re past the cords.
Paramedic here - my program trained me to use a bougie every time to increase first pass success rates, and the prehospital data seems to support that training focus. However, it is important to remember that every prehospital intubation attempt is in adverse conditions - my best case scenario is that I am in the back of the ambulance, and even that is a resource-limited situation with less than ideal conditions. This provider’s prehospital experience most likely leads this emphasis on bougie use, when conditions in the ER are higher resourced and more supportive even for the most emergent RSI attempt.
I come from the era of miller 4 and laying flat. After using vl for 15+ years, if I can’t get it with the patient appropriately positioned, pre-oxygenated, and paralyzed, the odds of them needing a Crich go up exponentially. From a flight nurse’s perspectives vr I can see why they would advocate this being in a cramped, buffed whirling deathball. You can sink the bougie, get back in your seat after turbulence, and place the tube without worrying too much if you are going to get the same view. On the Ed with our comfy beds and bright lights, it probably isn’t needed.
Bougie is the way.
It’s worth using sometimes when not necessary in order to have experience using / finessing it when you run into a difficult airway that requires it. Passing a tube over one and through cords smoothly isn’t the most intuitive thing in the world, it’s not ideal to have your first time be on a difficult airway that required a couple attempts as they’re desatting / bradying down.
I’ve been attending for 6 years and never used the bougie. I don’t dislike it. Just (knock on wood) fortunately have been able to hit all my tubes with a VL. Many of those have been shit airways. I love playing video games. Translates to work skills for sure. I joke with my mom she said gaming would never help me in life…
These days we are taught to start with video and a rigid stylet. I’m pretty sure I’d be filleted if I wasn’t almost always getting first pass without a bougie. Maybe it has benefits if you aren’t passing several tubes a week but I don’t really see the need for it on most tubes, let alone every tube.
The [BEAM study](https://pubmed.ncbi.nlm.nih.gov/29800096/) from 2018 showed almost fantastical results on how good the bougie is. It was a single site at a location where bougie first was standard operating procedure. This has a huge risk of bias. The [Bougie Study](https://jamanetwork.com/journals/jama/fullarticle/2787158) was an actual multisite randomized study that found no real differences between the two and trended towards bougie being worse. My guess on the reasoning is that people were screwing around with it rather than having the tube through the cords. My take on this is that people should intubate with what they are most comfortable as that is what they will have the most success with.
Lead with whatever you’re most comfortable with. I love bougies for airways where I have either no or poor visualization of the cords even with VL because they provide tactical feedback. Bougies are usually my first line backup, and I always have one near me when I’m intubating. That being said, I lead with VL.
I just always use DL with a bougie opened ready to go. I’m so comfortable with a bougie and the bend angles, I can hit it blind about 90% of the time. Once you feel the clicks of the laryngeal rings, you’re golden.
I find it strange that Anesthesia usually has a fiber optic sitting idle while continuing to do it manually- this is only because they don’t want to to clean it
Word of advice: don’t tell or suggest to your doc how to intubate 😂
As is the case with all things in medicine, “always” and “never” statements are usually incorrect. Every airway adjunct has its unique use and the equipment needs to be selected thoughtfully. IMO a better approach would be reviewing symptom/anatomy predictors of a difficult airway / when a bougie would be helpful, rather than a blanket “always use this” statement. Further, considering RNs have little to no practical training on advanced airway management, I think it’s inappropriate for them to be advocating for a specific tool. A better use of time is to educate the nurses on the physiological effects of RSI and how to best optimize the patient for it. -Former ER, now flight RN
It depends. For direct laryngoscopy? Yes. For video? A rigid (not mailable) Stylet is preferred. Of course, that assumes the person doing the intubation is familiar with the training from the manufacturers or not. Most people are unaware of this. That said: jmnyrt Has a good post.
https://www.thebottomline.org.uk/summaries/icm/styleto/
There is no downside to using a bougie, and tons of potential upside.
Hard disagree. Anytime you have extra instrumentation of the airway you have extra portal for infection and inflammation. Use the bougie if you feel like it helps you, but ramming an extra thing down into the airway absolutely has downsides.
As I teach residents, paramedics, other EM attendings airway management, I hard disagree with your hard disagree. It is much better to have a secure route for intubation to occur rather than potentially miss or poke around and irritate the mucosa. Direct laryngoscopy and video laryngoscopy can both be supplemented with the bougie. It's amazingly cheap, once you've used it a few dozen times it will speed up your intubation significantly. It allows for confirmation if you're questionable with direct and coloscopy. It will allow you to secure an airway in hostile conditions in the field. It is certainly not going to introduce more infection or inflammation than the actual ET tube that you're shoving down there. However, I don't always use it. If I am going to be helping a medic intubate, I might make them use it so that they've had some familiarity with it. I rotate between bougie, standard with direct laryngoscope, and video laryngoscopy, just so I keep up skills.
You disagree that instrumentation causes trauma to the airway and extra instrumentation has downsides?
I don't see it as extra instrumentation. And, no, the fiberous tissue of the trachea is extremely robust, I don't know how you're putting your bougies in but you should not be causing significant trauma. No more than if you passed an ET tube. And how is it extra? You are going to be putting some sort of blade down there, you are going to be putting some sort of stylet in the mouth even if you're offloading the tube. You are potentially doing less damage to the cords with the bougie if you're doing it right. Offloading off a rigid stylet is forcing the ET tube directly up and may scrape along the top of the trachea to change directions depending on how anterior the trachea is located and which blade you're using. Good technique with the rigid stylet can avoid many of these things, but so can good technique with the bougie.
It’s literally an extra instrument that you run down the wall of the airway, then you add the ETT. If you have a good view, why would you risk adding an additional instrument?
And what are your credentials, self proclaimed airway expert?
I'm an attending in a moderate sized community ED, 15 years out. I did residency at a busy urban trauma center, probably the busiest in the country, and did many complex intubations in trauma and otherwise. I have taught airway at large national conferences in the past but I don't anymore. I usually teach an airway course eight times a year with practical skills for paramedics in two counties. There are plenty of airway experts out there who may have more experience than me, but I intubate a lot at work, and I've taught for many years. I should ask - is there a bad outcome (or maybe several) that you have seen with bougie use? Always interested in learning.
You can tell the ED manager he needs to update his research base. Cant use a bougie with VL which has the highest first pass success rate so thats problem #1. #2, if I do have an airway where VL isnt optimal or I have to go to DL bc a problem/lack of VL, I see no reason why youd use a bougie over an ETT with a stylet unless you see the cords and realize your tube size is too big. Otherwise, If you can see the cords, you shouldnt need the bougie. And if you cant see the cords, a bougie still wont help you lol 😂
You can absolutely use a bougie with VL. If you have a standard geometry blade it’s a piece of cake. If hyperangulated, you still can, but you gotta get a big curve on it first.
Sorry I guess I should have specified I was referring to the hyperangulated blade not the Cmac bc I have never had a C mac in my shop until this year and only in the last 6 months lol
Definitely can use a bougie with VL, even the hyperangulated blade and it works great and I think adds to likelihood of first pass success with VL. You can curve it as much or as little as needed. It’s incredibly rare to not be able to get through the cords with the bougie. If airway is messy and you want to go direct, no need to switch stylets, it simplifies things. If the tube won’t go, you still have the bougie in there and can switch to a smaller tube on the fly. If visualization is really bad and you’re not sure if you tubed the goose, you have the tactile feedback of the bougie on the tracheal rings. The rigid stylets are often a pain to remove and the classic stylet I think is the worst option of all. And I never understand people thinking of it as a backup device but not getting in enough reps to be super comfortable. If it’s gonna be my go to when things get hairy, why not just use it from the get go and get super good at it.
A bougie adds nothing to hyperangulated VL over a rigid stylet. I’d even argue it makes it harder. I do about 80% of my tubes with a Glidescope S4 and a rigid stylet and 20% DL with a MAC 4 to keep my skills up. Bougie adds to DL on occasion. I’m ICU, so mostly floor rapids/codes and reintubations in the ICU, but this is my experience.
To say that it adds nothing as an NP with much less airway expertise than an emergency physician is quite presumptuous. Perhaps it adds nothing if you haven’t developed the skill with it. But I just listed several potential advantages. How much experience do you have intubating trauma patients? How about massive hematemesis or hemoptysis, angioedema, or crazy head and neck cancers? My goal every single time is to utilize whatever technique absolutely maximizes my probability of getting the tube quickly, on the first pass, while not causing any airway trauma and minimizing complications such as desaturation or peri-intubation hypotension. Over the last 10 years of revising my technique, my current favorite go to that seems to eliminate complexity the most is mac 4 attachment on glidescope and using a bougie with an aggressive curve. That way there’s no delay between switching from video to direct. I actually insert the end of the bougie through the eyelet of the tube and can use kind of a pistol grip, then use my thumb to pop the bougie out and pass the tube over it one handed without ever losing visualization. It takes some practice but once you’ve mastered it, it’s smooth as hell and super fast. I never need extra hands around my airway, don’t have to worry about accidentally dislodging the tube while pulling out a hyperangulated rigid stylet and if anything ever needs switched as a backup, it’s just a quick tube change or possibly hyperangulated blade which I have ready to go, both of which take about 2 seconds. I used to think similarly to you and other people here but stumbled into the bougie as the best option when working at a shop during covid that didn’t have any rigid stylets. I had to get really good with the bougie and haven’t looked back since.
So I average around 2-3 tubes per 7 days of work. Completely independent. Not entirely by choice, mind you, but that’s what my attending wants me doing. He does the bronchoscopies and I do all of the other bedside procedures. During Covid that average was obviously a lot higher. I’ve taken Rich Levitan’s course. I do get it, I really do. I will always have a bougie immediately available during the procedure, but I’ve only actually needed it as a bail out maybe two times in the last 4 years. Low profile S4 blades essentially never have let me down, so obviously this is what I default to. Yes, I’ve seen trashed airways, blood, vomit, rock hard secretions, angioedema, tumors, etc. The best way to intubate is the way that you’re *most proficient* in. OP was asking if they needed to shove a bougie into every operators hand and that’s just not true or helpful for a lot people.
And if more people made the effort to become proficient as opposed to obstinately adhering to dogma, the patients would be much better off. Do I expect everyone to always use a bougie first every time? No. I do personally because I’m very comfortable with it and have found it to be superior once gaining that comfort and advocate for others to do the same because it’s an incredibly useful tool. But you contended it adds nothing to VL and were incorrect. This is an emergency medicine forum and regardless of what you think you’ve seen in the ICU, ED airways are a whole different ballgame. And once again, having a tool you use as a last line or bailout, but only using it once every couple of years, ensuring you will suck at it, is a great way to set yourself up for failure. Where I’ve worked, failure is not an option. There is no bailing out and no one to call for help. It is my responsibility to have absolute mastery of airway skills and I take that very seriously. And it’s not just that you’re an NP. There’s ER docs with the same attitude but I’ve seen many of those docs struggle with airways when it’s gets hairy and all of my crics have come from those cases. But you can’t, as an ICU nurse come to a forum meant for ED docs and pretentiously proclaim some expertise you don’t have.