Evaluation of five static or dynamic tracheal tube introducers during standard and difficult intubations with C‐ MAC ® D‐blade videolaryngoscopy in a manikin*

Summary Introduction Tracheal tube introducers facilitate tracheal intubation and include stylets and static/dynamic bougies. There is uncertainty over the most efficacious introducer with hyperangulated videolaryngoscopy. Methods We evaluated five introducers. Thirty anaesthetists intubated a manikin 10 times with a reusable C‐MAC® D‐blade videolaryngoscope using five introducers in two airway setups. Airway setup was allocated randomly to standard or difficult tracheal intubation and the order of use of five introducers: two stylets (C‐MAC Stylet; Universal Stylet Bougie™); two dynamic bougies (Total Control Introducer™; Steerable Tracheal Intubation Guide™); and a static bougie (Portex® Bougie). The primary outcome was first‐attempt tracheal intubation success. Secondary outcomes were tracheal intubation within 120 seconds; time to tracheal intubation; and operator‐rated ease of tracheal intubation, railroading and force required. Results With the standard tracheal intubation setup, first‐attempt tracheal intubation success rates (95%CI) were: C‐MAC Stylet 100% (100–100%); Universal Stylet Bougie 93% (84–100%); Total Control Introducer 90% (79–100%); Steerable Tracheal Intubation Guide 80% (65–95%); and Portex bougie 57% (37–76%). With the difficult tracheal intubation setup, first‐attempt tracheal intubation success rates (95%CI) were: C‐MAC Stylet 93% (84–100%); Total Control Introducer 87% (74–99%); Universal Stylet Bougie 73% (56–90%); Steerable Tracheal Intubation Guide 60% (41–79%); and Portex bougie 33% (15–51%). The C‐MAC Stylet was best and the static bougie worst across all outcomes, with differences greater when tracheal intubation was designed to be difficult. In pairwise comparisons of tracheal intubation first‐attempt success in the difficult airway, the C‐MAC Stylet, Universal Stylet Bougie and Total Control Introducer were statistically significantly better than the Portex Bougie; the C‐MAC stylet was also statistically significantly better than the Steerable Tracheal Intubation Guide. Discussion Among introducers for hyperangulated videolaryngoscopy, stylets were most efficacious and a static bougie least. Differences in performance increased when tracheal intubation was difficult.