The Case for Bougie Use on Every Intubation

Tracheal tube introducer-associated airway trauma: a systematic review

BACKGROUND

Tracheal tube introducers are recommended in airway management guidelines and are used increasingly as videolaryngoscopy becomes more widespread. This systematic review aimed to summarise the published literature concerning tracheal tube introducer-associated airway trauma.

METHODS

PubMed, EMBASE and CINAHL databases were searched using pre-determined criteria. Two authors independently assessed search results and performed data extraction and risk of bias assessments.

RESULTS

We included 16 randomised controlled trials and five observational studies involving 10,797 patients. There was heterogeneity in patient characteristics, airway manipulation, and airway trauma definition and measurement. One study investigated hyperangulated videolaryngoscopy. The standard stylet was the most commonly reported introducer, followed by bougie and stylets with additional features such as video or lighted tip. Airway trauma resulted in low harm and most frequently involved injuries to the upper airway, followed by laryngeal and tracheobronchial injuries. Eighteen studies were comparative and reported a reduction in airway trauma incidence when an introducer was used, with the exception of the standard stylet. Median (IQR [range]) pooled incidence of airway trauma associated with standard stylets was 13.1% (4.2-31.4 [0.5-79.2])% and with bougies was 5.4% (0.4-49.9 [0.0-68.0])%. The risk of bias of included studies was variable and many randomised trials were found to be at high risk due to non-robust measurement of the outcome.

CONCLUSIONS

Stylets might be associated with an increased risk of airway trauma compared with other devices or when no stylet was used, though the quality of evidence is modest. However, other introducers appear to be safe and reduce the risk of airway trauma.

Selective intubation with endotracheal tube introducer in difficult airway: A randomized, prospective, cross-over study

BACKGROUND:

Selective lung intubation is a life-saving procedure in emergency departments. While various equipment can be used in selective lung intubation, most of this equipment is not readily available; therefore, single-lumen endotracheal intubations are performed for rapid interventions.

MATERIALS AND METHODS:

This study was designed as a randomized, prospective, cross-over study using the 90° rotation technique for selective intubation on a manikin model with and without endotracheal tube introducer (ETI) in difficult airway settings. Forty-six emergency physicians were included in the study. The primary outcome was evaluating time to selective intubations, and secondary outcomes were first and second attempt success rates and the self-perceived difficulty level of each method according to the participants.

RESULTS:

The mean time to the first successful endotracheal intubation was significantly longer for both right selective and left selective intubations with ETI utilization than without ([39.71 ± 9.83 vs. 21.86 ± 5.94 s], [P < 0.001]), ([42.2 ± 10.81 vs. 26.23 ± 7.97 s], [P < 0.001], respectively). The first-pass success rate did not differ for right selective intubation with or without an ETI (45/46 [97.8%] and 45/46 [97.8%], respectively). However, the first-pass success rate for left selective intubation was significantly higher with ETI as compared to without an ETI (30/46 [65.2%] and 13/46 [28.3%], respectively) (P < 0.001).

CONCLUSIONS:

While the success rates of right selective intubation were the same, the left selective intubation success rates with ETI are higher than the styletted endotracheal tube, which can be strong evidence for this method's applicability in practice. Expanding the use of ETI and increasing the experience of the practitioners can contribute to further success.

George J. A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities

Background

There is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult-not emergency-intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX.

Methods

This is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience.

Results

The mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation.

Conclusions

This study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.