Flexible-tip bougie vs. stylet for tracheal intubation with a hyperangulated videolaryngoscope in critical care: a randomised controlled trial.

Abstract

The optimal introducer for tracheal intubation with a hyperangulated blade videolaryngoscope for patients in the ICU remains uncertain. Both stylets and flexible-tip bougies have been used, yet there is limited evidence on which is more efficacious. We conducted a randomised controlled trial comparing flexible-tip bougie vs. stylet using a hyperangulated blade videolaryngoscope (C-MAC^® D-blade). Adults admitted to the ICU who required tracheal intubation were included. Primary outcome was first-attempt tracheal intubation success. Secondary outcomes included the number of tracheal intubation attempts; tracheal intubation difficulty; and incidence of complications. A total of 140 patients were allocated randomly (40 female (29%); mean (SD) age 68 (13.0) y). First-attempt tracheal intubation success was higher in patients allocated to flexible-tip bougie (69/70, 99%) compared with stylet (58/70 (83%), p = 0.005). The proportion of patients' tracheas intubated in one, two or three attempts was 69/70 (99%), 1/70 (1%) and 0/70 (0%) in the flexible-tip bougie group, compared with 58/70 (83%), 7/70 (10%), and 5/70 (7%) in the stylet group, respectively. More patients in the stylet group required laryngeal manipulation (22/70 (31.4%)) during tracheal intubation compared with the flexible-tip group (7/70 (10%)). Anaesthetists rated 69/70 (99%) of tracheal intubations with the flexible-tip bougie as not difficult or slightly difficult compared with 63/70 (90%) for the stylet group. No significant difference in the incidence of complications was observed between the two techniques. In the ICU, first-attempt tracheal intubation success with a hyperangulated blade videolaryngoscope was higher using the flexible-tip bougie than the stylet. No differences were observed in operator difficulty or complication rates between the two techniques.