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A comparison of multiple‐use and single‐use bougies

2005; Wiley; Volume: 60; Issue: 4 Linguagem: Inglês

10.1111/j.1365-2044.2005.04168.x

1365-2044

A. Whitcombe, T. Strang, J. Reay,

Tactile and Sensory Interactions

Hodzovic et al. [1] found that the currently available single-use bougies are inferior to the older, multiple-use bougie. In an independent comparison we also looked at the three devices: the multiple-use Eschmann Gum Elastic Bougie (SIMS Portex, Hythe, UK); the single-use Portex Tracheal Tube Introducer (SIMS Portex); and the Frova Intubating Introducer (Cook UK Ltd, Letchworth, UK). Ethics approval for this study was sought, but was deemed unnecessary by the Local Research Ethics Committee. Thirty-three anaesthetists (20 consultants, 9 Specialist Registrars and 4 SHOs) participated. A Laerdal Airway Management Trainer was used with a Macintosh size 3 laryngoscope blade held by a retort stand and clamp to simulate a Cormack and Lehane grade 3 laryngeal view. Following an observation by Lim et al. [2], a pillow was placed under the manikin's head to more closely approximate the ‘sniffing the morning air’ position. The three bougies were used in random order, and the anaesthetist was asked to attempt to cannulate the trachea using their usual bougie technique. Moulding and lubrication of the bougies was allowed, but no adjustment could be made to the manikin or laryngoscope. External laryngeal pressure was not permitted. The frequencies of successful and unsuccessful intubations with the three different bougies were tabulated and stratified for grade of anaesthetist. Fisher's exact tests with Bonferroni corrections for multiple comparisons were used to compare the bougies. In addition, multinomial logistic regression analysis was used to assess the effects of type of bougie and grade of anaesthetist on outcome. Relative risk ratios for failed intubation were estimated for the three bougies. The Frova Intubating Introducer resulted in the most successful tracheal placements, with 29 of the 33 anaesthetists being successful. This compares with 17 correct placements using the multiple-use and nine with the single-use SIMS Portex devices. Use of the single-use (p = 0.0003) and multiple-use (p = 0.0008) devices was associated with less successful tracheal placement than the Frova device. The relative risks for failed intubation using the single use device compared to the Frova Intubating Introducer and the multiple use device were 6.0 (95% CI [2.2, 18.6]) and 1.5 (95% CI [0.93, 2.6]), respectively. Consultants and Specialist Registrars were both significantly more successful than their SHO colleagues (p = 0.02). Although this study produced similar findings to that of Hodzovic et al. we found that the Frova Intubating Introducer produced significantly fewer oesophageal intubations than the other two devices. The single-use Portex device was only successful in 27% of cases, which is unacceptable for a device designed to be used in cases of unexpected difficult intubation. Annamaneni and colleagues also looked at the pressure that can be exerted by the tips of each device [3]. While it is possible to exert greater pressure on the trachea with the Frova introducer, therefore increasing the potential risk of tracheal trauma, there are a number of steps that can be taken to reduce this risk. As suggested, these include adequate lubrication, avoiding advancement of the bougie to elicit the hold up sign, and the avoidance of excessive force at all times. It is our opinion that the Frova Intubating Introducer is a viable long-term replacement to the Gum Elastic Bougie. We would like to thank Dr Malachy Colomb for help with the statistics. Thank you for asking Smiths Medical to reply to Dr Whitcombe's letter. We accept that results will vary on comparisons conducted on different manikins, testing equipment and experience of the user on all three different introducers. The reusable bougie used today was designed and conceived by Dr Paul Venn and introduced in 1973. It has proven itself as a valuable aid to difficult intubation [1-4], regarded as the gold standard by clinicians globally [5] and its performance has been difficult to replicate in a single-use introducer [5, 6]. For this reason alone, we were surprised at the oesophageal intubation results with the Portex Venn (formally known as Eschmann) bougie against the Frova. Obviously manikins are a reasonable facsimile for training purposes but may not always reflect real life experience developed over 30 years of world-wide use.