Comparison of the single‐use plastic bougie and the multiple‐use gum elastic bougie for tracheal intubation in simulated grade‐3 difficult laryngoscopy

Abstract

The gum elastic bougie is the most common aid used to facilitate intubation duringgrade-3 laryngoscopy. Traditionally in the United Kingdom, the multiple-use gum elastic bougie has been used [1], which is washed (but not sterilised) between uses. With increasing concern regarding multiple-use devices and cross-infection, a new single-use plastic bougie has been introduced. Anecdotally, it appears that any bougie which lacks flexibility and curvature, is more difficult to use [2]. The purpose of this study was to compare success rates for tracheal intubation in simulated Cormack and Lehane Grade-3 laryngoscopy. With Local Research Ethics Committee approval and after obtaining written informed consent, we studied 32 ASA 1 and 2 adult patients (day-case dental procedures). Simulation of grade-3a laryngeal views (epiglottis only just obscuring the view of the arytenoids) was achieved by lowering the Macintosh laryngoscope blade [3]. One operator maintained the laryngoscope in position while another commenced intubation. Patients were randomised to either the single-use plastic bougie or multiple-use gum elastic bougie. If the intubation failed with the first device (one attempt only), the alternative study device was used. Success rates and intubation times were recorded. Statistical comparison was with the χ2 or t-tests, with p < 0.05 taken as statistically significant. The multiple-use bougie was successful in 15/16 cases; the single-use bougie in only 9/16 cases (p < 0.041). Of the seven cases which failed with the single-use bougie, the multiple-use bougie was successful in five. The single-use bougie was successful in the single case in which the multiple-use bougie failed. Total intubating times were under 85 s in all cases, and there were no significant differences between the groups. The difference in success rates between the multiple-use and single-use bougies is striking. Although minimising the risk of cross-infection is important, it is of concern that the newly introduced device performs less well and introduces the more important risk of failed intubation. It is not possible to blind a study such as this, and it would be very important for others to repeat our findings, to minimise the risk of bias. A rational approach would be to suggest that, where a bougie is to be used routinely, the single-use plastic bougie may be used; where it is used to facilitate an urgent intubation, the multiple-use gum elastic type should be used. Alternatively, in the latter instance, a fibreoptic scope may also be used.