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

Summary Introduction 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. Methods 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. Results 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. Discussion 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.