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Difficult intubation, the bougie and the stylet
  1. Ian Jones, Registered Paramedic,
  2. Katherine Roberts, Research officer
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; kevin.mackway-jones{at}


    A short cut review was carried out to establish whether a gum elastic bougie is more effective than a stylet at improving the success rate in difficult intubation. Altogether 32 papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of this best paper are tabulated. A clinical bottom line is stated.

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    Report by Ian Jones,Registered ParamedicChecked by Katherine Roberts, Research officer

    Clinical scenario

    A paramedic ambulance is dispatched to a 36 year old woman who has fallen from a horse. On arrival the rider is not wearing a helmet, is unconscious, and has laboured diaphragmatic breathing. A cervical spine injury is suspected and orotracheal intubation is indicated because of the reduced respiratory effort, possible head injury, and the long transport time to the nearest emergency department. The patient has a grade 3 laryngoscopic view (Cormack and Lehane). You wonder whether intubation would be made easier if you had a gum elastic bougie or stylet.

    Three part question

    In a [restricted view intubation] is the [gum elastic bougie more effective than a stylet] at [improving the intubation success rate]?

    Search strategy

    Medline and HealthStar 1966–06/02 using the OVID interface. [{exp intubation, intratracheal OR intubat$.mp OR intubation$.mp OR exp intubation OR exp laryngoscopy OR} AND { OR bougie$.mp OR gum OR stylet$.mp}] LIMIT to human AND English.

    Search outcome

    Altogether 334 papers found of which one was relevant. This is shown in table 7.

    Table 7


    The use of simulated views is less than ideal. Despite this drawback the results clearly answer the question posed. A further study comparing the bougie, the lighted and unlighted stylet in both grade 3 and grade 4 views would be useful.


    The gum elastic bougie is superior to the stylet at increasing the intubation success rate, when tested on simulated grade 3 views.

    Report by Ian Jones,Registered ParamedicChecked by Katherine Roberts, Research officer