Stylet or Bougie for Intubation

As many of you will know, I’ve been teaching airway workshops now for many years, and have put over 3500 doctors through the Advance Airways Workshop.

I teach equipment in the following way:
Your weapon of choice is the size 3 curved blade.
Everyone gets a 7.5 tube in the emergency situation
Always use a stylet and bend the end so it looks like a bougie
My back up: a Bougie

Now I know there has been some work done on the bougie vs the stylet, but I was recently told that the stylets are so “yesterday” and everyone is using a bougie first now. Really? I want to look at the literature on this.

In a 20 year old study¹ they found that the gum elastic was superior to the stylet in terms of intubation success rate when tested on simulated Grade 3 view. This study used simulated views rather than actual and they didn’t consider Grade 4 views.

Noguchi et al ² compared the gum elastic bougie to a stylet when applying cricoid pressure.  Well, I can stop right there, because cricoid pressure is out. But let’s persevere. The conclusion was that the gum elastic bougie was superior over the stylet for tracheal intubation during cricoid pressure application.

There were some potential limitations including the study design, bias and that those applying cricoid pressure, were not blinded. The most important finding however is that the success rate and duration of intubation was not clinically different between stylet and bougie. …………So, it’s of no use to us.

Here is a recent study. This was a randomised control trial ³ carried out on 56 patients. A difficult airway was simulated by application of a rigid cervical collar. Now this study does make me think a little. It isn’t the manikin studies done in the past which showed low success rates of stylet compared to bougie (66%) ⁴.

Arguments made against the stylet include the potential for damage to soft tissue as well as effectively intubating blind. In respect to the last comment, the stylet is no different to the bougie, where you are intubating blind.

The technique I’ve always taught is to place the tube in, in such a way, that you are intubating for below upwards, giving you a direct view.

My take on all this is that you use what you are used to. 

You will always perform better with this approach. In manikin Intubation models where operators were used to stylets, the success rate with stylets overshadowed the bougie significantly i.e by twice as much.⁵

So my approach stays the same:

1. Size 3 Macintosh Blade
2. Size 7.5 Endotracheal tube
3. Stylet (not protruding past the edge and bent at 35° angle) 
4. If difficult, try a bougie. 

1. Getaure PS, Vaughan RS, Latto IP. Simulated difficult intubation in patients with potential cervical spine injuries. An indication for the gun elastic bougie. Anaesthesia 193, 18: 630-33

2. Noguchi T, Koga K, Shinga Y, Shigematsu A. The gum elastic bougie eases tracheal intubation while applying ericoid pressure compared to a stylet. Canadian Journal of Anaesthesia 2003; 50:7: 712-717

3. Kahn R, Ashraf Kan F, Azam M. Comparison of the stylet and gum elastic bougie in tracheal intubation in a simulated difficult airway. Anaesthesia Pain and Intensive Care. 2014; 18 (3): 256-259

4. Paul AK. Drugs and equipment in Anaesthesia Practice. Elsevier, New Delhi, 2004. 252.

5. Gregory P, Wollard M,  Lighton D, Munro G, Jenkinson E, Newcombe RG, O’Meara P, Hamilton L. Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation. Anaesthesia 2012, 67, 371-376