Bougie as a Backup? Why I’m Moving It to Plan A
It’s three in the morning, and the airway in front of me is a mess. Angioedema has swollen the tissues, there’s blood pooling at the back of the throat, and when I get my blade in and lift, I’m rewarded with the worst view in the business: a Cormack-Lehane grade 3. No cords. Just a sliver of arytenoid and a whole lot of nope.
So I reach for a long, skinny, slightly bent piece of plastic — the bougie. I feel for the tracheal rings, I get the hold-up sign, I rail-road the tube over the top, and we’re in. Crisis averted.
Here’s what bugged me for years afterward. When I trained, the bougie was the backup — the break-glass-in-case-of-emergency tool, Plan B. And if it’s that good when everything goes sideways, why am I not reaching for it on the first attempt, every time? That question is the whole episode.
The bougie debate has a great origin story, because it’s a story about a result that didn’t replicate. In 2018, the BEAM trial out of Hennepin County reported a jaw-dropping first-attempt success of 98% with a bougie versus 87% with a standard styletted tube — an 11-percentage-point absolute difference. The bougie evangelists, myself included, lost their minds. Then in 2021, the same group ran the larger, multicenter BOUGIE trial in critically ill adults and found nothing: no significant difference. The headline effect evaporated. The 2022 American Society of Anesthesiologists difficult-airway guidelines have sat on the fence ever since — endorsing adjuncts like the bougie for anticipated difficult airways, but stopping short of recommending them for everyone.
When good trials disagree, that is exactly what a meta-analysis is for.
The study is a 2024 systematic review and meta-analysis from von Hellmann and colleagues, published in Annals of Emergency Medicine. A medical librarian searched five databases from inception to June 2023. The team screened 3,915 records, reviewed 134 full-text articles, and landed on 18 studies — 12 randomized controlled trials and 6 observational studies — totaling 9,151 patients across out-of-hospital, emergency department, ICU, and operating-room intubations. It was pre-registered on PROSPERO, used dual independent reviewers and random-effects models, and rated certainty with GRADE. One exclusion matters: studies using only hyper-angulated video laryngoscopy or channeled devices, because you can’t easily rail-road a bougie around a hyper-angulated blade. This is a standard-geometry story.
Pooling all 18 studies, bougie use was associated with higher first-attempt success — a relative risk of 1.11 (95% CI 1.06–1.17), an 11% relative improvement in landing the tube on the first pass. In the emergency-department studies specifically (9 studies, just over 8,000 patients), the effect held at RR 1.11. And in patients with a genuinely difficult view — Cormack-Lehane grade 3 or 4 — the relative risk jumped to 1.60 (95% CI 1.40–1.80), although only 5 studies and roughly 585 patients informed that subgroup.
The safety picture is honest. There was a signal toward more minor airway trauma with the bougie (RR 1.55, 95% CI 1.00–2.39), intubations ran slightly longer (up to about 13 seconds on average in ED studies), and there was no significant difference in hypoxemia or esophageal intubation.
Now the caveats, because loving a tool doesn’t mean ignoring the weaknesses in the paper that defends it. The heterogeneity was high — an I² of 83% — because the authors pooled calm, optimized OR patients with crashing trauma patients who have blood in the airway. Those aren’t the same intubation. GRADE rated overall certainty as low, six observational studies drag in confounding, and a funnel-plot asymmetry hints at publication bias. The primary outcome — first-attempt success — is a process measure, not a patient-centered one. And the biggest caveat is the operator-skill problem: BEAM hit 98% at a center that lives and breathes the bougie, while the multicenter BOUGIE trial, with mixed experience, found nothing. The honest read isn’t “the bougie is magic.” It’s “the effect depends heavily on who’s holding it.”
How Should This Modify Your Practice?
First, consider promoting the bougie from Plan B to Plan A — deliberately. With a standard-geometry blade, my new default is bougie-first — not because the average effect is huge, but because you can’t predict which airway will be the grade-3 until you’re already in it.
Second, match the tool to the blade. The bougie wants a standard-geometry view — direct laryngoscopy or a standard-geometry video blade. If your department defaults to hyper-angulated video laryngoscopy, stay fluent in standard-geometry DL plus bougie anyway, because the day the camera fogs or the screen dies, that’s your bailout.
Third, respect the skill curve. You get good at what you practice. Train the bougie deliberately — simulation, the Kiwi grip, reps on routine airways — so the movement is automatic when the anatomy is ugly.
Fourth, don’t ignore the small downsides. A few extra seconds and a signal toward minor trauma mean “bougie on everything reflexively” isn’t free. Once you have a clean grade-1 view, a styletted tube is perfectly reasonable. The point isn’t dogma — it’s having the bougie loaded, in your hand, and in your muscle memory before you need it.
Where I land: I’m moving the bougie to first-line, and I’m booking sim time to make that real rather than aspirational. Practicing the change is the change.
Author
Dr. Adrian Cois, MD — Emergency Medicine physician, medical educator, and host of Overheard in the Emergency Room. Find more evidence-based medicine for everyday people at DrCois.com.
Disclosure: This article is for educational purposes only and does not constitute medical advice or establish a physician–patient relationship. The author has no financial relationship with any manufacturer of bougies, laryngoscopes, or airway equipment.
Related reading
• Overheard Journal Club: Video vs. Direct Laryngoscopy — the standard-geometry companion to this episode (DrCois.com)
• The full Overheard Journal Club archive (DrCois.com)
• Listen to this episode on Spotify and watch on YouTube — links at DrCois.com
References (AMA)
1. von Hellmann R, Fuhr N, Maia IWA, et al. Effect of Bougie Use on First-Attempt Success in Tracheal Intubations: A Systematic Review and Meta-Analysis. Ann Emerg Med. 2024;83(2):132-144. doi:10.1016/j.annemergmed.2023.08.484
2. Driver BE, Prekker ME, Klein LR, et al. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation (BEAM). JAMA. 2018;319(21):2179-2189. doi:10.1001/jama.2018.6496
3. Driver BE, Semler MW, Self WH, et al. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation (BOUGIE). JAMA. 2021;326(24):2488-2497. doi:10.1001/jama.2021.22002
4. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology. 2022;136(1):31-81. doi:10.1097/ALN.0000000000004002
5. Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults (DEVICE). N Engl J Med. 2023;389(5):418-429. doi:10.1056/NEJMoa2301601
