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Research Analysis: Airway management better with the bougie

A randomized clinical trial of ED intubations showed a statistically significant improvement in first pass success rates when using a bougie


The trial was powered to focus on patients with a difficult airway.

Courtesy photo

Researchers at Hennepin County Medical Center and the University of Minnesota Department of Emergency Medicine recently published the results of the Bougie Use in Emergency Airway Management (BEAM) randomized clinical trial in the Journal of the American Medical Association (JAMA).

The BEAM trial compared intubations done in a Level I trauma center using a Macintosh blade, with and without a bougie. Patients were randomly assigned to each group and all intubations were done by either a senior emergency medicine resident or an attending physician.

The trial was powered to focus on patients with a difficult airway, including “body fluid(s) obscuring the laryngeal view, airway obstruction or edema, obesity, short neck, small mandible, large tongue, facial trauma or cervical spine immobilization.” However, because the researchers were incapable of knowing if an airway would be difficult, they collected information on non-difficult airways, as well.

A total of 757 patients were enrolled in the trial, and of the 381 that were randomized to use a bougie, 198 had a difficult airway (of which 96 percent had a first-pass success). Of the 376 patients randomized to the endotracheal tube and stylet, 182 had a difficult airway and 82 percent were intubated on the first pass. The p-value between these two groups was 0.001.


The authors concluded their paper with the following statement: “Use of a bougie compared with an endotracheal tube and stylet resulted in significantly higher first-attempt intubation success among patients undergoing emergency endotracheal intubation.”

Memorable quotes on bougie use in difficult airways

Other memorable quotes in the article included:

“Routine bougie use was associated with increased first-attempt success in a retrospective study in the ED; however, to our knowledge, there have not been randomized clinical trials assessing its efficacy.”

“Among the 56 patients (7 percent) in both groups who were not intubated on the first attempt, subsequent attempt(s) were successful with the help of several rescue techniques, including the bougie, in 49 patients, the intubating laryngeal mask airway in one patient and cricothyrotomy in one patient.”

“In light of the significant association between first-attempt intubation success and fewer intubation-related adverse events in previous research, the bougie may be beneficial as a primary intubation device rather than solely as a rescue adjunct.”

“Because laryngeal views were comparable between groups, these findings suggest that passing the device into the trachea is simpler with a bougie compared with an endotracheal tube and stylet.”

Key takeaways on bougie use in airway management

Here are four key takeaways on using bougies in airway management:

1. Airway management randomized control trials are important

This is the first randomized control trial to show that bougies increase first-pass intubation success rates. While this trial was conducted in the more “stable” environment of a Level I trauma center, the results will likely translate to the prehospital setting.

2. Bougie isn’t just a rescue device

The mental model around bougies is evolving. They aren’t just for use after multiple failed attempts. And, since most medical directors are emergency-medicine trained physicians, this newer opinion may start to seep into an EMS agency near you.

3. Bougies save time overall

Since using a bougie means passing two objects down the trachea, it makes sense that any single intubation attempt took an average of four seconds longer if the bougie was used. However, because the bougie group had a greater first-pass success rate, the overall time spent from the start of the first intubation attempt until the patient was successfully intubated was shorter by a statistically significant amount.


4. More research on bougies is needed

While comparing video vs. direct laryngoscopy may be the current hot topic in prehospital airway management, this article opens the door for research on bougie use in the prehospital setting.

Additional articles on airway management

Here are additional EMS1 resources on airway management:

Catherine R. Counts, PHD, MHA, is a health services researcher with Seattle Medic One in the Division of Emergency Medicine at the University of Washington School of Medicine. She received both her PhD and MHA from Tulane University School of Public Health and Tropical Medicine.

Dr. Counts has research interests in domestic healthcare policy, quality, patient safety, organizational theory and culture, and pre-hospital emergency medicine. She is a member of the National Association of EMS Physicians and AcademyHealth. In her free time she trains Bruno, her USAR canine.

Connect with her on Twitter, Facebook, or her website, or reach out via email at