• Brian E Driver, Matthew W Semler, Wesley H Self, Adit A Ginde, Stacy A Trent, Sheetal Gandotra, Lane M Smith, David B Page, Derek J Vonderhaar, Jason R West, Aaron M Joffe, Steven H Mitchell, Kevin C Doerschug, Christopher G Hughes, Kevin High, Janna S Landsperger, Karen E Jackson, Michelle P Howell, Sarah W Robison, John P Gaillard, Micah R Whitson, Christopher M Barnes, Andrew J Latimer, Vikas S Koppurapu, Bret D Alvis, Derek W Russell, Kevin W Gibbs, Li Wang, Christopher J Lindsell, David R Janz, Todd W Rice, Matthew E Prekker, Jonathan D Casey, and BOUGIE Investigators and the Pragmatic Critical Care Research Group.
• Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota.
• JAMA. 2021 Dec 28; 326 (24): 248824972488-2497.

ImportanceFor critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.ObjectiveTo determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt.Design, Setting, And ParticipantsThe Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021.InterventionsPatients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546).Main Outcomes And MeasuresThe primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%.ResultsAmong 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.Conclusions And RelevanceAmong critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.Trial RegistrationClinicalTrials.gov Identifier: NCT03928925

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