Intubating Stylets in the Emergency Department: A Video Review of First-pass Success and Time

Effective airway management is critical for optimal patient outcomes in the emergency department (ED). Additionally, airway management is significantly influenced by the clinician's selection of equipment, specifically the choice of intubating stylet. Also of note, the duration of intubation (time to intubate) impacts overall success. The choice of intubation device may influence first-pass success and intubation times. In this study we evaluated equipment trends for first-pass success and intubation duration. We collected data by reviewing a video database of recorded airways. Three commonly used intubating stylets were reviewed: the hyperangulated stylet; bougie (Eschmann stylet); and malleable stylet.

In this retrospective observational study, we reviewed 615 intubation videos. These videos were recorded via video laryngoscopy at the University of Kansas Medical Center and The University of Kansas Health System between February 2019-January 2022. We recorded device type, number of intubation attempts, and time to successful intubation (time from entry of laryngoscope blade to passage of endotracheal tube through vocal cords). We included and analyzed 575 intubations for first-pass success, while a random subset of 70 intubations was used to evaluate intubation times. We also conducted a survey to query current faculty and resident physicians regarding their preference for intubation modality.

Among 575 intubations, the bougie (Eschmann stylet) was used in 47.1% of cases, the malleable stylet in 27.3%, and the hyperangulated (also known as "rigid" or "angular") stylet in 25.6%. Overall first-pass success was 91.3%. The malleable stylet showed the highest success rate (94.9%), followed by the hyperangulated stylet (93.2%), and the bougie (88.2%) (χ² = 6.53, P = .04). In a separate analysis of 70 cases, the median intubation time was 35.5 seconds. For intubation time, we found a significant difference between the three modalities (χ² = 8.2019, P = .02), with pairwise differences between bougie vs malleable stylet (P = .01) and bougie vs hyperangulated stylet (P = .02), but not between hyperangulated and malleable stylets (P = .62). Bougie-assisted intubations had the highest median time of 40.5 seconds (mean 49.15 +/- 23.1) compared to malleable stylet 31 seconds (mean 33.8 +/- 16.4) and hyperangulated 31 seconds (mean 33.6 +/- 11). A survey of 52 physicians showed that 55.8% preferred the malleable stylet, 19.2% preferred the hyperangulated stylet, and 25% preferred the bougie.

The malleable stylet demonstrated the highest first-pass success rate and the most consistent intubation times, while the bougie had the longest times and lowest success rate in our ED. Physician preferences also favored the malleable stylet. First-pass success rates and intubation times vary depending on an institution's familiarity with specific devices and the clinician's preference. These factors should be considered when selecting intubation equipment to optimize airway management outcomes or facilitate training.