Does the use of a bougie reduce the force of laryngoscopy in a difficult airway with manual in-line stabilisation?: a randomised crossover simulation study

Abstract

CONTEXT: Manual in-line stabilisation is usually used during tracheal intubation of trauma patients to minimise movement of the cervical spine and prevent any further neurological injury. Use of a bougie in combination with laryngoscopy may reduce the forces exerted on the cervical spine. OBJECTIVE: To evaluate the difference in force applied to the head and neck during tracheal intubation with a Macintosh laryngoscope with or without simultaneous use of a bougie. DESIGN: Randomised, crossover simulation study. SETTING: Simulation laboratory, Anaesthetic Department, Queen's Hospital, Romford between March and April 2012. PARTICIPANTS: Twenty anaesthetists, all with a minimum of 1 year of anaesthetic experience. INTERVENTIONS: Participants used either a Macintosh laryngoscope alone, or in combination with a bougie in a Laerdal SimMan manikin with a simulated difficult airway and manual in-line stabilisation. MAIN OUTCOME MEASURES: The force exerted during laryngoscopy. Success rate and time taken to tracheal intubation were also measured. RESULTS: Significantly less force was exerted utilising a Macintosh laryngoscope in combination with a bougie compared with the laryngoscope alone (24.9 versus 44.5 N; P < 0.001). The trachea was successfully intubated on all occasions within 120 s. The use of a bougie was associated with a nonsignificant reduction in the time to tracheal intubation. CONCLUSION: To minimise the force of laryngoscopy and movement of a potentially unstable cervical spine injury, consideration should be given to the early use of a bougie.