Difficult intubation, the bougie and the stylet
Date First Published:
February 14, 2002
Last Updated:
September 16, 2002
Report by:
Ian Jones, Registered Paramedic (Prehospital Emergency Research Unit, Lansdowne Hospital, Cardiff)
Search checked by:
Katherine Roberts, Prehospital Emergency Research Unit, Lansdowne Hospital, Cardiff
Three-Part Question:
In a [restricted view intubation] is the [gum elastic bougie more effective than a stylet] at [improving the intubation success rate]?
Clinical Scenario:
A paramedic ambulance is dispatched to a 36-year-old female who has fallen from a horse. On arrival the rider is not wearing a helmet, is unconscious with a GCS of 3 and has laboured diaphragmatic breathing. A cervical spine injury is suspected and orotracheal intubation is indicated due to the reduced respiratory effort, possible head injury and the long transport time to the nearest emergency department. The patient has a grade 3 laryngoscopic view (Cormack and Lehane). You wonder whether intubation would be made easier if you had a gum elastic bougie or stylet.
Search Strategy:
Medline and HealthStar 1966-06/02 using the OVID interface.
Search Details:
[{exp intubation, intratracheal OR intubat$.mp OR intubation$.mp OR exp intubation OR exp laryngoscopy OR laryngospcopy.mp} AND {introducer.mp OR bougie$.mp OR gum elastic.mp OR stylet$.mp}] LIMIT to human AND English.
Outcome:
334 papers found of which 1 was relevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet. Gataure PS, Vaughan RS, Latto IP. 1996, UK | 100 patients undergoing elective surgery randomly split into 2 equal groups. Group 1 were intubated using 2 attempts with a bougie followed by a stylet while group 2 were intubated with 2 attempts with a stylet followed by a bougie. Simulated grade 3 views were used. Bougie vs stylet |
RCT | Success rate after 2 attempts | 48/50 (96%) vs 33/50 (66%) p < 0.001 | Not tested with grade 4 views The study did not compare lighted stylets against bougies and unlighted stylets The study used simulated difficult intubations rather than actual difficult intubations |
| Mean time for 2 intubation | 30.1 sec vs 36.6 sec |
Author Commentary:
The use of simulated views is less than ideal. Despite this drawback the results clearly answer the question posed. A further study comparing the bougie, the lighted and unlighted stylet in both grade 3 and grade 4 views would be useful.
Bottom Line:
The gum elastic bougie is superior to the stylet at increasing the intubation success rate, when tested on simulated grade 3 views.
References:
- Gataure PS, Vaughan RS, Latto IP.. Simulated difficult intubation. Comparison of the gum elastic bougie and the stylet.