Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis

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.