A Comparison of a Fiberoptic Stylet and a Bougie as Adjuncts to Direct Laryngoscopy in a Manikin-Simulated Difficult Airway

Study objective: We compare the effectiveness of an endotracheal tube introducer ("bougie") with a new fiberoptic stylet as an adjunct to direct laryngoscopy in facilitating simulated difficult tracheal intubation in a manikin. Methods: Inexperienced laryngoscopists were recruited for this randomized, crossover study. After brief training, participants were randomized to first use either the bougie or fiberoptic stylet as an adjunct to direct laryngoscopy for attempted tracheal intubation of a manikin presenting a fixed, simulated, Cormack-Lehane grade IIIA view. Two attempts at tracheal intubation were allowed, each limited to 60 seconds. The participant then crossed over and used the other device. The same procedure was then repeated on a second manikin presenting a simulated Cormack-Lehane grade IIIB view. Primary outcomes were time to tracheal intubation and successful endotracheal tube placement. Results: One hundred three study participants performed a total of 533 tracheal intubations for evaluation. For the Cormack-Lehane grade IIIA view, correct placement of the endotracheal tube was achieved in 101 (98%) of the fiberoptic stylet-facilitated and all 103 (100%) of the bougie-facilitated tracheal intubations. The time to successful tracheal intubation was similar for both devices (difference in mean time 1.8 seconds; 95% confidence interval [CI] -2.5 to 6.1 seconds). In the Cormack-Lehane grade IIIB view manikin, use of the fiberoptic stylet significantly increased success rate (fiberoptic stylet 98% versus bougie 9%), and a trend was observed toward a decrease in the mean time required for successful tracheal intubation compared to the bougie (fiberoptic stylet 31.0 seconds versus bougie 45.6 seconds; difference in mean time -14.6 seconds; 95% CI -31.4 to 2.3 seconds). Conclusion: In a manikin model, with inexperienced clinicians, both the bougie and the fiberoptic stylet were effective in facilitating tracheal intubation of a simulated Cormack-Lehane grade IIIA view. For a Cormack-Lehane IIIB view, the fiberoptic stylet was significantly more effective than the bougie in facilitating tracheal intubation. Because a manikin model eliminates some of the barriers to use of fiberoptics in patients, further validation of fiberoptic stylet use is required in human subjects with normal and difficult airways.