Use Of Bougie Research Articles

Improving airway management in pediatric emergency intubation: A narrative review with a focus on bougie guidance in settings with limited resources

AbstractBackgroundEffective airway management in pediatric emergency settings, especially in resource‐limited environments, presents unique challenges that necessitate innovative solutions.ObjectivesThis review investigates the role of bougie‐guided pediatric intubation as a crucial technique in addressing these challenges.MethodsA comprehensive search of peer‐reviewed literature was conducted using reputable databases such as PubMed, Scopus, Google Scholar, and Web of Science. Suitable keywords and Medical Subject Headings terms were employed. Data extraction focused on study design, patient demographics, intervention protocols, primary outcomes, and safety profiles. A qualitative synthesis was performed to provide a comprehensive narrative review.ResultsPediatric bougies, known for their cost‐effectiveness and adaptability, emerge as promising tools for successful and efficient pediatric intubation. Comparative studies indicate that bougie use results in superior first‐pass success rates and reduced intubation times. Case studies highlight the bougie's versatility in managing difficult pediatric airways.ConclusionsThe bougie's cost‐effectiveness positions it as a practical solution to disparities in treatment levels. Successful pediatric intubation in resource‐limited settings requires improved accessibility, standardized proficiency, and infrastructure readiness. Integrating the bougie into pediatric airway management guidelines represents a proactive approach to these challenges.

Impact of Toupet fundoplication with bougie on post-operative dysphagia and quality of life.

Numerous studies comment on quality of life outcomes comparing complete and partial fundoplication with or without a bougie. Society guidelines are moving toward recommending partial fundoplication over complete fundoplication due to improved side effect profile with similar outcomes. Retrospective studies and randomized trials have elucidated that use of a bougie during Nissen fundoplication does impact long-term dysphagia. To date there are no retrospective or prospective data that guide practice for partial fundoplications. The purpose of this project is to investigate the clinical implications of using a bougie for Toupet fundoplication with regard to short-term and long-term dysphagia and need for further therapeutic interventions. A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic, pre-operative quality of life outcomes data, perioperative, and post-operative quality of life outcomes data of 373 patients from 2011 to 2022 undergoing Toupet fundoplication without bougie or with a traditional Savary 56Fr or 58Fr bougie were reviewed. The two groups were compared using student's t-test to identify statically significant differences between the groups. Between 2011 and 2022, 373 patients underwent Toupet fundoplication (276 with traditional bougie, 97 without). Median follow-up in the bougie group was 19months, versus 9months in the non bougie group. There was no difference between early (3weeks) and late dysphagia scores (6months). In the bougie group there were two mucosal perforations due to the bougie. There were no statistically significant differences in GERD-HRQL, gas bloat, and dysphagia scores between groups at one year. There is no difference observed in early or late dysphagia scores, GERD-HRQL, gas bloat or need for dilation in patients undergoing Toupet fundoplication with or without a traditional bougie. It is reasonable to discontinue the use of a traditional bougie during Toupet fundoplication, especially due to risk of esophageal perforation.

PERI-OPERATIVE ANAESTHETIC CONCERNS IN COVID-19 ASSOCIATED MUCORMYCOSIS

Introduction: Mucormycosis is a fulminant life-threatening fungal infection requiring emergency surgical debridement. It is associated with immune-compromised status, multi-systemic involvement, and difficult airway posing challenges to anesthetic management. We conducted this study to find the peri-operative anesthesia concerns in patients of COVID-19-associated mucormycosis Methods: This retrospective observational study included COVID-19-infected patients operated for invasive mucormycosis under general anesthesia. Cases operated under local anesthesia were excluded from the study. Results: A total of 30 patients were included in the study where the majority of the patients were ASA physical status III. ASA classification uses a grading system of l(one) through V( five), with I identifying a person in good health and V as a person with a severe, life-threatening condition. The most common co-morbidity was diabetes mellitus plus hypertension 66% (n=20), followed by only diabetes 30% (n=9). Out of all patients, 33.3% (n=10) were intubated at the first attempt using direct laryngoscope, rest 66.6% required other interventions like the use of video laryngoscope, bougie, or external laryngeal pressure. Perioperative blood transfusion was required in 40% (n=12) of the patients. Of patients who required intensive care unit (ICU) admission 40% (n=12) out of them, 10% patients (n=3) did not survive. The average hospital stay was 55.9 +/-15.8 days with a maximum of 95 days and a minimum of 15 days. Conclusion: Mucormycosis is mostly associated with uncontrolled diabetes milletus in post-COVID patients. These require utmost care peri-operatively as they are associated with a difficult airway, intraoperative complications, prolonged morbidity, and mortality.

Comparison of Paraglossal Technique of Miller Blade Insertion with McCoy and Macintosh Adult Laryngoscopes on the Cormack–Lehane Grade in Patients with Simulated Restricted Neck Mobility—A Randomized Control Trial

Abstract Background The paucity in round-the-clock availability of advanced tools like flexible bronchoscopes and video laryngoscopes makes it preferable to have alternative easily available gadgets for securing the airway in patients with cervical spine injuries where head and neck movements must be strictly avoided. This study compared the paraglossal technique of Miller blade insertion with the McCoy and Macintosh laryngoscope blades on the Cormack and Lehane grading (CLG) in patients with simulated restricted neck mobility. Methods We randomized 90 patients undergoing general anesthesia to be intubated either using Miller blade (Group-Mill), McCoy blade (Group-McCoy), or Macintosh blade (Group-Mac) following neck restriction using a soft cervical collar. CLG grade, the number of intubation attempts, use of bougie, intubation time, and hemodynamic parameters were noted. Nonparametric data were compared using the chi-squared test and parametric data using one-way analysis of variance. Results Group-MILL had significantly higher patients with Grade-1 CLG compared to Group-Mac (p = 0.02). The number of attempts, use of bougie, and intubation time were, however, comparable among the three groups. The hemodynamic parameters at intubation were not significantly different among the groups. Conclusion In adult patients with simulated restricted neck, the Miller laryngoscope blade, despite providing a better laryngeal view, showed no benefit in decreasing the intubation time when compared to the McCoy or Macintosh blades.

The Efficacy of Utilizing Bougie Vs Stylet in Patients Requiring Endotracheal Intubation: Updated Systematic Review and Meta-Analysis

Introduction: Endotracheal intubation is a high-risk procedure that can be lifesaving for critically ill or injured patients. Assisted devices, such as the bougie and stylet, are commonly used to improve success rates and reduce complications. The bougie facilitates the passage of the endotracheal tube through the vocal cords while the stylet is inserted into the endotracheal tube prior to intubation. However, there is variation in clinical practice regarding the preference for using these devices in difficult airway management. Methods: This systematic review and meta-analysis included randomized controlled trials (RCTs) that compared the efficacy of bougie versus stylet in tracheal intubation. Medline, Embase, Cochrane Central of Controlled Trials and Clinical trials.gov were searched for studies discussing the same topic. The primary outcome was the first-attempt intubation success rate between the bougie and stylet. Our secondary outcomes were to compare the duration of intubation and the complications rates between bougie and stylet. Results: A total of 7 RCTs that enrolled participants(number?) were eligible. The bougie approach had a slightly higher success rate on the first attempt, but there was no significant difference between the methods (RR, 1.01; 95% CI, 0.90 to 1.15). The duration of intubation, pooled analysis indicated a statistically significant reduction in the duration of intubation with the stylet approach compared to the bougie approach (MD, 8.39; 95% CI, 2.87 to 13.91). Subgroup analysis revealed lower rates of esophageal intubation (RR, 0.65; 95% CI, 0.26 to 1.61, I2= 0%) and pneumothorax (RR, 0.94; 95% CI, 0.54 to 1.66, I2= 0%) in the bougie group. Conclusion: This study reported that no significant difference between the use of bougie vs stylet in terms of first attempt intubation success rates and the complication rates of endotracheal intubation. However, stylet displayed significantly shorter duration of intubation in comparison to bougie.

Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis

The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded. A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level. We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty). In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.

The impact of the bougie size and the extent of antral resection on weight-loss and postoperative complications following sleeve gastrectomy: results from the Scandinavian Obesity Surgery Registry

BackgroundThe optimal sleeve diameter and distance from the pylorus to the edge of the resection line in laparoscopic sleeve gastrectomy (LSG) remain controversial. ObjectivesTo evaluate the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG. SettingNationwide registry-based study. MethodsThis study included all LSGs performed in Sweden between 2012 and 2019. Data were obtained from the Scandinavian Obesity Surgery Registry. Reference bougie size of 35–36 Fr and an antral resection distance of 5 cm from the pylorus were compared to narrower bougie size (30–32 Fr), shorter distances (1–4 cm), and extended distances (6–8 cm) from the pylorus in assessing postoperative complications and weight loss as the outcomes of LSG. ResultsThe study included 9,360 patients with postoperative follow-up rates of 96%, 79%, and 50% at 30 days, 1 year, and 2 years, respectively. Narrow bougie and short antral resection distance from the pylorus were significantly associated with increased postoperative weight loss. Bougie size was not associated with increased early or late complications. However, short antral resection distance was associated with high risk of overall early complications [odds ratio: 1.46 (1.17–1.82, P = .001)], although no impact on late complications at 1 and 2 years was observed. ConclusionsUsing a narrow bougie and initiating resection closer to the pylorus were associated with greater maximum weight loss. Although a closer resection to the pylorus was associated with an increased risk of early postoperative complications, no association was observed with the use of narrow bougie for LSG.

Facilitated Intubation: Time to Re-examine an Old Technique With Its Associated Risks Mitigated by New Technology.

Facilitated intubation (FI) refers to intubation performed using a sedative or anesthetic drug as an induction agent, without the use of a paralytic (neuromuscular blocking agent). In comparison, rapid sequence intubation (RSI) employs both an induction agent and a paralytic drug. RSI has been seen to outperform FI in terms of first-pass success when performing direct laryngoscopy and was quickly adopted as the gold standard in all situations. Recently, ketamine-only intubation has been used in situations where there is distorted anatomy or apnea intolerance (physically and physiologically difficult airways) resulting in an increased risk of a can't intubate/can't oxygenate scenario or significant hypoxemia. Frequent and recurring national ketamine shortages have resulted in renewed interest in whether or not other forms of FI are feasible in an era where other factors that mitigate complictions in achieving first-pass success (video laryngoscopy, bougie use, semi-Fowler positioning) are commonly used. We present a case series with outcomes for profoundly hypoxic patients with coronavirus disease 2019 (COVID-19) (physiologically difficult airways) undergoing FI during a time of national ketamine shortage, using modern techniques and technology to maximize first-pass success and minimize peri-intubation complication. We included patients with COVID-19 pneumonia with pre-intubation oxygen saturations of less than 80% (significant hypoxemia) requiring intubation who presented to a tertiary care center in southern United States between August 25, 2021, and October 22, 2021.In this specific cohort, patients underwent endotracheal intubation with midazolam for induction without the use of paralytic agents.We used video-assisted laryngoscopy to increase the success of the first-pass attempt as well as placing the patients in a semi-Fowler position (head of bed elevation 30-45°) and bilevel positive pressure pre-oxygenation to minimize peri-intubation complications. Our case series included 29 consecutive patients that met the inclusion criteria.The mean ± standard deviation (SD) age of the patients was 49.5±15.0 years. The mean±SD pre-intubation oxygenation of our cohort was 73.1±5.9%.All 29 intubations were successful on the first-pass attempt.Only one patient (3.4%) required a rescue paralytic to facilitate oral opening. Of note, 27/29 (93%) of the patients did not receive any immunizations (including partial) for COVID-19.There were no incidents of peri-intubation arrest (cardiac arrest within 30 minutes of induction) or aspiration. In 29 physiologically difficult patients with acute respiratory failure, in whom the physician determined that RSI posed a higher than normal risk, FI assisted by VL, semi-Fowler positioning, and bilevel positive pressure pre-oxygenation resulted in excellent successful first-pass intubation rates without any incidencesof peri-intubation arrestor aspiration.While this cohort was small, our study reveals that FI with midazolam does not likely pose a higher risk than ketamine-only intubationand warrants further study.

The Pediatric Bougie for the First Tracheal Intubation Attempt in Critically Ill Children.

Bougie use during emergency tracheal intubation has not been well studied in children. This was a 10-year observational study of pediatric intubations (<18 years of age) in the emergency department (ED) of an academic institution. Bougie training and use are standard in our ED, including for emergency medicine residents. Study data were collected by a combination of charts and video reviews. We compare first-attempt intubation success and procedural complications between pediatric patients with and without bougie use during tracheal intubation in the ED. In addition, we evaluate the independent association of bougie use with first-attempt intubation success using multivariable logistic regression. We collected data on intubation success and bougie use for 195 pediatric patients over more than 10 years. On the first tracheal intubation attempt, a pediatric bougie was used in 126 patients (65%). Median patient age was 5 years (interquartile range 1.7 to 9) in the bougie group and 1.7 years (interquartile range 0.2 to 5) in the no bougie group. Intubation was successful on the first attempt in 72% of intubations with a bougie versus 78% without a bougie (absolute difference -6%, 95% confidence interval [CI] -19 to 6%); the adjusted odds of first-attempt success with a bougie were 0.54 (95% CI 0.24 to 1.19). A procedural complication occurred for 38% of patients in the bougie group versus 51% in the no bougie group (-13%, 95% CI -27% to 2%). Two neonates, one in each group, experienced a potential injury to the airway or lower respiratory tract. In an academic ED where the bougie is commonly used, bougie use in children was not associated with procedural success or complications. Our study suggests that a randomized clinical trial is needed to determine the effect of bougie use during emergency pediatric intubation.

Association of airway obstruction with first-pass success and intubation-related adverse events in the emergency department: multicenter prospective observational studies.

Airway obstruction is a relatively rare but critical condition that requires urgent intervention in the emergency department (ED). The present study aimed to investigate the association of airway obstruction with first-pass success and intubation-related adverse events in the ED. We analyzed data from two prospective multicenter observational studies of ED airway management. We included adults (aged ≥18 years) who underwent tracheal intubation for non-trauma indications from 2012 through 2021 (113-month period). Outcome measures were first-pass success and intubation-related adverse events. We constructed a multivariable logistic regression model adjusting for age, sex, modified LEMON score (without airway obstruction), intubation methods, intubation devices, bougie use, intubator's specialty, and ED visit year with accounting for patients clustering within the ED. Of 7,349 eligible patients, 272 (4%) underwent tracheal intubation for airway obstruction. Overall, 74% of patients had first-pass success and 16% had intubation-related adverse events. The airway obstruction group had a lower first-pass success rate (63% vs. 74%; unadjusted odds ratio [OR], 0.63; 95% CI, 0.49-0.80), compared to the non-airway obstruction group. This association remained significant in the multivariable analysis (adjusted OR 0.60, 95%CI 0.46-0.80). The airway obstruction group also had a significantly higher risk of adverse events (28% vs. 16%; unadjusted OR, 1.93; 95% CI, 1.48-2.56, adjusted OR, 1.70; 95% CI, 1.27-2.29). In the sensitivity analysis using multiple imputation, the results remained consistent with the main results: the airway obstruction group had a significantly lower first-pass success rate (adjusted OR, 0.60; 95% CI, 0.48-0.76). Based on these multicenter prospective data, airway obstruction was associated with a significantly lower first-pass success rate and a higher intubation-related adverse event rate in the ED.

First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department

AimTracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused. MeasurementsWe reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success. ResultsWe reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued. ConclusionsIt was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.

The Effect of Sizing Device Use During Laparoscopic Sleeve Gastrectomy on Rates of Postoperative Dehydration and Other 30-day Complications: An Analysis of the ACS-MBSAQIP Database

During laparoscopic sleeve gastrectomy (LSG), many surgeons use an intraoperative sizing device. However, the choice of intraoperative sizing device varies and the optimal choice or combination of sizing devices, such as a bougie or esophagogastroduodenoscopy (EGD), is not known. The purpose of this study was to determine if there is an association between the use of a sizing device or a combination of sizing devices on rates of dehydration, bleeding, and staple line leak following LSG. Patients between the ages of 18 to 80 who underwent elective LSG were identified using the American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (ACS-MBSAQIP) database from 2015 to 2019. Postoperative outcomes, including rates of dehydration, bleeding, and staple line leak, were compared across 4 groups: those that utilized bougie and EGD (both), those that utilized only bougie (bougie only), those that utilized only EGD (EGD only), and those that did not utilize either sizing device (neither). In all, 533,151 cases met the inclusion criteria. On univariate analysis, the bougie-only group experienced the highest rates of dehydration events. On multivariate analysis, the use of both sizing devices was associated with significantly lower odds of events related to dehydration versus bougie only (aOR 0.869, P =0.0002), and bougie only was associated with significantly higher odds of events related to dehydration versus EGD only (aOR 1.773, P =0.0006).The neither-sizing device group did not show any statistically significant differences in any of the comparisons. Bougie use alone was associated with more dehydration-related complications, while EGD use demonstrated a protective effect. Not using a sizing device was associated with equivalent outcomes to all combinations of sizing devices. These findings highlight the need for the standardization of sizing devices during LSG and suggest that foregoing sizing devices may be a management option without early adverse sequelae.

840: TO BOUGIE OR NOT TO BOUGIE: META-ANALYSIS COMPARING FIRST-ATTEMPT INTUBATION WITH BOUGIE AND STYLET

Introduction: Endotracheal intubation is a life-saving procedure with several indications. Successful placement of the endotracheal tube on the first attempt greatly reduces the risk of complications. The endotracheal introducer (commonly known as the bougie) and the stylet are two different devices used to facilitate orotracheal intubations in various settings. The aim of this systematic review and meta-analysis is to compare the likelihood of successful first attempt intubation using either of the two devices. Methods: A search was performed on PubMed, Cochrane, and Web of Science. We used the following mesh terms, “(endotracheal intubation) OR (orotracheal intubation) AND (bougie) OR (gum elastic bougie) OR (endotracheal introducer) OR (stylet)” from the 01/01/2000 to 07/15/2022. We screened 3100 articles out of which 4 randomized controlled trials comparing the use of bougie and stylet were included in this systematic review. Studies performed on cadavers/mannequins, population age less than 18, and out-of-hospital intubations were excluded from this review. Results: This systematic review and meta-analysis consisted of 4 randomized controlled trials with a total population of 1962. The mean age for the bougie group was 52.7 years and the stylet group was 52.8 years. The average body mass index for the bougie and stylet groups was 26.8 Kg/m2 and 27.1 Kg/m2, respectively. When a random effects model was applied, the metanalysis did not show any significant differences in the first attempt success rate with a risk ratio of 0.957; 95% confidence interval, 0.833 to 1.100. Reported complications included hypoxemia, esophageal intubation, pneumothorax, and cardiovascular collapse with no significant differences in the two groups. Conclusions: The bougie and stylet had comparable rates of first attempt intubation with neither being superior to the other. The healthcare provider should take into consideration their ease and comfort of intubation with each technique before opting for one during intubation.

Effect of two barrier devices on the time taken and ease of intubation of a paediatric intubation manikin - A randomised cross-over simulation study.

During the present COVID-19 pandemic, several inventions have been employed to protect personnel involved in intubation from inhalational exposure to the virus. In this study, we compared the effect of two barrier devices, Intubation Box versus Plastic Drape, on the time taken and difficulty in intubating a pediatric manikin. Nineteen experienced anesthesiologists performed six different intubations: without barrier, with intubation box, with plastic drape; with and without a bougie, using the Latin Square Design for randomizing order of intubations. The time taken for intubation (TTI) was compared using Student's t test, and nonparametric values were analyzed using Chi-square test with Yates correction. Both barrier devices increased the TTI from 14.8 (3.5) s to 19.8 (6.8) s with intubation box (P = 0.068) and 19.3 (8.9) s with plastic drape (P = 0.099). Use of bougie significantly prolonged TTI to 25.8 (6.7) s without barrier (P = 0.000), 32.5 (13.3) with intubation box (P = 0.000), and 29.8 (7.3) s with plastic drape (P = 0.000). The number of attempts was not different (P = 0.411), and the visibility was slightly impaired with both barriers (P = 0.047). The ease of intubation, even without the bougie, was significantly different compared to default, with P values of 0.009 and 0.042 for intubation box and plastic drape, respectively. The highest significance was with intubation box with bougie with a P value of 0.00017. Both the intubation box and plastic drape increased the time taken as well as difficulty in intubation. The extra protection afforded should be balanced against risks of hypoxia in the patient.

Examination of Primary Bougie Use in Air Medical Intubations

<h3>Introduction</h3> Use of a bougie during emergency rapid sequence intubation (RSI) appears to increase first attempt success but may increase time to a definitive airway. This analysis was performed to explore primary use of a bougie during air medical RSI. <h3>Methods</h3> For this analysis, patients undergoing RSI by air medical crews were identified from a large air medical database. First attempt success (FAS), and first attempt success without desaturation (FASWD) were used as outcome measures. Patients in whom a bougie was used during the initial intubation attempt were compared to patients undergoing intubation without the bougie. Propensity scores for bougie use were calculated and multiple logistic regression used to calculate odds ratios for both outcome measures. <h3>Results</h3> A total of 11,836 air medical RSI patients were identified. Patients in whom a bougie was used on the first attempt had more difficult airway predictors. Logistic regression analysis with propensity adjusted odds ratios revealed no associations between use of a bougie on first attempt and FAS (adjusted OR 0.92, 95% CI 0.80-1.05, p=0.212). However, FASWD rates were statistically significantly lower with use of a bougie on first attempt after adjusting for age, gender, trauma, and presence of difficult airway criteria (adjusted OR 0.85, 95% CI 0.75-0.96, p=0.009). <h3>Conclusion</h3> Primary use of the bougie during intubation resulted in similar rates of first pass success when compared to non-bougie group. Primary bougie use may be associated with a higher rate of desaturation during first attempt intubation. Limitations include the potential for selection bias not addressed by the statistical models. Further examination to explore the effects of bougie use related to desaturation is recommended.

Routine Intraoperative Use of Esophageal Bougie in Minimally Invasive Hiatal Hernia Repair is Not Necessary.

Laparoscopic hiatal hernia repair can be performed with an antireflux procedure. Routine use of an esophageal bougie has been advocated to avoid an excessively tight fundoplication. The use of an esophageal bougie carries a risk of iatrogenic complications, such as perforation or laceration of the viscera. However, there is equivocal evidence for the routine use in the surgical literature. We present a retrospective analysis of patients with Types 3 and 4 paraesophageal hiatal hernias who underwent laparoscopic hiatal hernia repair with fundoplication without the use of an esophageal bougie, between December 1, 2010 and February 28, 2020, by a single surgeon at a community-based, academic hospital. Patients with a diagnosis of achalasia and gastroesophageal dysmotility were excluded. Perioperative outcome measures included: recurrence; prolonged postoperative proton pump inhibitor use; dysphagia; re-operation, and mortality. A total of 174 patients (34 males, 140 females) underwent laparoscopic hiatal hernia repair with fundoplication. The average age was 63-years old. Four patients (2.3%) developed dysphagia with narrowing of the gastroesophageal junction, with one patient (0.6%) requiring postoperative esophageal dilation with bougie and eventual re-operation. Postoperative proton pump inhibitor use was 31.0% after 1 month. Overall hernia recurrence rate was 14.9% and the rate of re-operation was 6.3%. Overall mortality was 0.6%. We conclude that laparoscopic hiatal hernia repair with fundoplication without an esophageal bougie is safe, effective, and efficient. Furthermore, bougie related risks are obviated with a comparable reported incidence of postoperative dysphagia and hiatal hernia recurrence.

Drug-free tracheal intubation by specialist paramedics (critical care) in a United Kingdom ambulance service: a service evaluation

BackgroundDrug-free tracheal intubation has been a common intervention in the context of out-of-hospital cardiac arrest for many years, however its use by paramedics has recently been the subject of much debate. Recent international guidance has recommended that only those achieving high tracheal intubation success should continue to use it.MethodsWe conducted a retrospective service evaluation of all drug-free tracheal intubation attempts by specialist paramedics (critical care) from South East Coast Ambulance Service NHS Foundation Trust between 1st January and 31st December 2019. Our primary outcome was first-pass success rate, and secondary outcomes were success within two attempts, overall success, Cormack-Lehane grade of view, and use of bougie.ResultsThere were 663 drug-free tracheal intubations and following screening, 605 were reviewed. There was a first-pass success rate of 81.5%, success within two attempts of 96.7%, and an overall success rate of 98.35%. There were ten unsuccessful attempts (1.65%). Bougie use was documented in 83.4% on the first attempt, 93.5% on the second attempt and 100% on the third attempt,ConclusionSpecialist paramedics (critical care) are able to deliver drug-free tracheal intubation with good first-pass success and high overall success and are therefore both safe and competent at this intervention.

Safety of rapid sequence intubation in an emergency training network.

Rapid sequence intubation (RSI) is a core critical care skill. Emergency medicine trainees are exposed to relatively low numbers of RSIs. We aimed to improve patient outcomes by implementing an RSI checklist, electronic learning and audit, in line with current best evidence. Prospective observational study of RSIs performed in the EDs of two Queensland hospitals between January 2014 and December 2016. Data collected included: first-pass success (FPS), predicted difficulty, indication for intubation, drugs used, positioning, number of attempts, checklist use and complications. Descriptive statistics and multivariable modelling were used to describe differences in FPS, and complications. Six hundred and fifty-five patients underwent RSI with FPS of 86.6%. Complications were reported in 15.9%, mainly hypotension (10.9%) and desaturation (4.0%). FPS improved with bougie use (88.9% vs 73.0% without bougie, P < 0.001) and video-laryngoscopy (88.2% vs 72.9% using standard laryngoscopy, P < 0.001). New desaturation was reduced with apnoeic oxygenation (2.0% vs 22.2%, P < 0.001), bougie use (2.8% vs 8.9%, P < 0.001), checklist use (2.3% vs 22.7%, P < 0.001) and achieving FPS (2.1% vs 16.3%, P < 0.001). Complications were reduced with checklist use (13.3% vs 43.2%, P < 0.001) and apnoeic oxygenation use (3.9% vs 31.1%, P < 0.001). Logistic regression found checklist use was associated with reduced desaturation (OR 0.1, 95% CI 0.04-0.27) and the composite variable of any complication (OR 0.39, 95% CI 0.17-0.89). Implementation of an evidence-based care bundle and audit of practice has created a safe environment for trainees to learn the core critical care skill of RSI. In our setting, checklist use was associated with fewer complications.

Routine Use of a Bougie Improves First-Attempt Intubation Success in the Out-of-Hospital Setting

The bougie is typically treated as a rescue device for difficult airways. We evaluate whether first-attempt success rate during paramedic intubation in the out-of-hospital setting changed with routine use of a bougie. A prospective, observational, pre-post study design was used to compare first-attempt success rate during out-of-hospital intubation with direct laryngoscopy for patients intubated 18 months before and 18 months after a protocol change that directed the use of the bougie on the first intubation attempt. We included all patients with a paramedic-performed intubation attempt. Logistic regression was used to examine the association between routine bougie use and first-attempt success rate. Paramedics attempted intubation in 823 patients during the control period and 771 during the bougie period. The first-attempt success rate increased from 70% to 77% (difference 7.0% [95% confidence interval 3% to 11%]). Higher first-attempt success rate was observed during the bougie period across Cormack-Lehane grades, with rates of 91%, 60%, 27%, and 6% for Cormack-Lehane grade 1, 2, 3, and 4 views, respectively, during the control period and 96%, 85%, 50%, and 14%, respectively, during the bougie period. Intubation during the bougie period was independently associated with higher first-attempt success rate (adjusted odds ratio 2.82 [95% confidence interval 1.96 to 4.01]). Routine out-of-hospital use of the bougie during direct laryngoscopy was associated with increased first-attempt intubation success rate.

마네킹을 이용한 어려운 기도에서 부지 기관 내 삽관의 효과

Purpose: This study aimed to find out the effectiveness of gum elastic bougies for intubation in comparison to stylet according to airway type using a manikin. Methods: The study subjects were 52 paramedic students who intubated using a Macintosh laryngoscope and compared stylet and gum elastic bougie use in a 7.5 mmID endotracheal tube, on a manikin with either normal or difficult airway. Difficult airway was made Philadelphia neck collar. Collected data included intubation time, accuracy and ease of intubation, later analyzed by frequency analysis, descriptive analysis, independent t-test, chi square test, paired t-test, and McNemar test using SPSS Statistics 18.0. Results: There was a significant difference in intubation time according to intubation device and airway type (p=.000). There was no significant difference in accuracy of intubation according to intubation device or airway type (normal airway p=1.000, difficult airway p=.052). There was a significant difference in ease of intubation scale according to intubation device and airway type (p=.000, p=.000). Conclusion: Based on the speed and ease of intubation, gum elastic bougie is recommended for intubation in patients with difficult airways such as those with cervical injury.