The Bougie Revisited

The Bougie Revisited 468 416 Richie Cunningham

A little over a year ago I was lucky enough to write a post for on the bougie which can be found here. A more detailed version of this initial blog post was later published in ACEPNow as “The Bougie as an Airway Savior.” These were my first contributions to the FOAMed movement and led to me starting the Copa Strong blog with Jon Kelley and Brendan Tarzia. So in recognition of the one year anniversaries of these publications, I’d like to share what I have since learned about this ingenious little device.

A Nifty Maneuver

While doing an impromptu airway lesson during one of my teach shifts this year, a medical student who had worked as a critical care paramedic prior to pursuing medicine shared with me a neat little trick. If you position the bougie between two fingers, you can “scissor” your fingers together to create an extra bend. This will help sneak the coudé tip anteriorly into the airway in case you have a limited view of the cords. Below is a visual representation of this.

A Nifty Device

Another discovery came by way of an industrious paramedic out of Texas who happened to read my ACEPNow article. He was kind enough to send me some free samples of a device he created to help grip a bougie called the Bougie Ray (pictured below). I’ve been able to trial it myself and have let several co-residents use it. One now uses it every time he uses a bougie. Definitely worth giving it a shot if you have one, though unfortunately I can’t find them for sale on the website… I’ll shoot the guy an email and will update here if I hear back.

A Literature Update

Since my last look at the bougie, a new trial has been published looking at its effect on first-pass success in intubation. The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial is the first multicenter, randomized clinical trial to evaluate the effect of the bougie on first-pass success in intubation. It randomized patients in 15 emergency departments and ICUs to undergo intubation with either a bougie or an endotracheal tube loaded over a stylet.

Much to my dismay, the BOUGIE trial found no difference in first-pass success of intubation between the two groups. (80.4% in the bougie group vs 83% in the stylet group, p=0.27). So have I been mistaken all along in my love for the bougie? Not quite…

I’ve always argued that in order to find success with a bougie, you have to use it. The BEAM trial was an RCT that showed a 98% first-pass success rate with a bougie compared to 87% with a stylet. One “limitation” of this study was that it was conducted at Hennepin County Medical Center, a bougie center of excellence where the device is used routinely in all first attempts at intubation. 

In contrast, in the BOUGIE trial, 14 of the 15 centers used a bougie on the first attempt either “sometimes” or “rarely” prior to enrollment in the study. What’s more, the median number of attempts with a bougie per proceduralist prior to the study was only 10. In my experience, it takes a few dozen attempts with the bougie to really know how to manipulate it and find success passing it blind, which is its main advantage.

Another interesting limitation that can only be found in the supplement to the paper is that 11/15 centers formed a bend in the bougie prior to intubation only “sometimes” or “rarely.” Anyone who knows how to use a bougie properly knows to use its malleability to form a slight bend in it to follow the curvature of the oropharynx into the airway (see pictures earlier in this post). Otherwise passing a perfectly straight bougie (or straight anything!) into the airway is incredibly difficult. I’d recommend you try doing so on an airway mannequin to see what I mean. So not only did the proceduralists in this study lack experience with the bougie, they were using it the wrong way the majority of the time!

So while this study was well-done and has statistically significant results, I think if anything it counterintuitively implies that in order to take advantage of the bougie we should be using it on every intubation. By doing so I think you’ll find your success rate matches more closely with the BEAM trial than the BOUGIE trial. 


  1. 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: A Randomized Clinical Trial. JAMA. 2021;326(24):2488-2497. doi:10.1001/jama.2021.22002
  2. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. PMID: 29800096; PMCID: PMC6134434.