Success of the gum elastic bougie as a rescue airway in the emergency department

Background: The gum elastic bougie (GEB) is a rescue airway device commonly found in the emergency department (ED). However, data documenting its efficacy are lacking in the emergency medicine literature. Study Objectives: To determine the success rate of endotracheal intubation using a GEB and the reliability of "palpable clicks" and "hold-up" in the ED setting. Methods: The GEB was introduced at our two affiliated urban EDs with a 3-year residency training program and an annual census of 150,000. Physicians were trained in the use of the GEB before initiation of the study. Over the course of 1 year, we conducted a prospective, observational study of GEB practices in the ED. The study population included all adult patients on whom intubation was attempted with a GEB. All emergency physicians attempting intubation completed a structured data form after laryngoscopy, recording patient characteristics, grade of laryngeal view (using the modified Cormack-Lehane classification), and presence of "palpable clicks" and "hold-up." Indications for GEB use in our ED include a difficult or rescue airway and for training purposes. Data were analyzed using standard statistical methods and 95% confidence intervals. Results: In our study period, there were 26 patients on whom intubation was attempted with a GEB. The overall success rate was 20/26 (76.9%; 95% confidence interval [CI] 60.793.1%). Among cases where the GEB was used for training purposes (all grade 1 or 2a laryngeal view), six of seven (85.7%) intubations were successful. When the GEB was used for clinically indicated purposes, 14 of 19 (73.7%; 95% CI 53.993.5%) intubations were successful. Palpable clicks were appreciated in 11/20 successful intubations (sensitivity 55.0%; 95% CI 33.276.8%); there was one false positive (specificity 80%; 95% CI 40.998.2%). Of 20 successful intubations, hold-up was deferred in five cases; of 15 remaining cases, hold-up was appreciated in 5/15 (sensitivity 33.3%; 95% CI 9.557.2%); there were no false positives (specificity 100%; 95% CI 60.7100%). Conclusions: In our ED setting, the GEB had a success rate of 73.7% when utilized as a rescue airway after failed attempts. The characteristics of "palpable clicks" and "hold-up" were unreliable.