Success of the Gum Elastic Bougie as a Rescue Airway in the Emergency Department

Abstract

The gum elastic bougie (GEB) is a rescue airway device commonly found in the emergency department (ED). However, data documenting its efficacy are lacking in the emergency medicine literature. To determine the success rate of endotracheal intubation using a GEB and the reliability of "palpable clicks" and "hold-up" in the ED setting. The GEB was introduced at our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000. Physicians were trained in the use of the GEB before initiation of the study. Over the course of 1 year, we conducted a prospective, observational study of GEB practices in the ED. The study population included all adult patients on whom intubation was attempted with a GEB. All emergency physicians attempting intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), and presence of "palpable clicks" and "hold-up." Indications for GEB use in our ED include a difficult or rescue airway and for training purposes. Data were analyzed using standard statistical methods and 95% confidence intervals. In our study period, there were 26 patients on whom intubation was attempted with a GEB. The overall success rate was 20/26 (76.9%; 95% confidence interval [CI] 60.7-93.1%). Among cases where the GEB was used for training purposes (all grade 1 or 2a laryngeal view), six of seven (85.7%) intubations were successful. When the GEB was used for clinically indicated purposes, 14 of 19 (73.7%; 95% CI 53.9-93.5%) intubations were successful. Palpable clicks were appreciated in 11/20 successful intubations (sensitivity 55.0%; 95% CI 33.2-76.8%); there was one false positive (specificity 80%; 95% CI 40.9-98.2%). Of 20 successful intubations, hold-up was deferred in five cases; of 15 remaining cases, hold-up was appreciated in 5/15 (sensitivity 33.3%; 95% CI 9.5-57.2%); there were no false positives (specificity 100%; 95% CI 60.7-100%). In our ED setting, the GEB had a success rate of 73.7% when utilized as a rescue airway after failed attempts. The characteristics of "palpable clicks" and "hold-up" were unreliable.