von Hellmann Rafael, Fuhr Natalia, Ward A Maia Ian, Gerberi Danielle, Pedrollo Daniel, Bellolio Fernanda, Oliveira J E Silva Lucas
Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil.
Department of Emergency Medicine, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil.
Ann Emerg Med. 2024 Feb;83(2):132-144. doi: 10.1016/j.annemergmed.2023.08.484. Epub 2023 Sep 19.
The use of a bougie, a flexible endotracheal tube introducer, has been proposed to optimize first-attempt success in emergency department intubations. We aimed to evaluate the available evidence on the association of bougie use in the first attempt and success in tracheal intubations. This was a systematic review and meta-analysis of studies that evaluated first-attempt success between adults intubated with a bougie versus without a bougie (usually with a stylet) in all settings. Manikin and cadaver studies were excluded. A medical librarian searched Ovid Cochrane Central, Ovid Embase, Ovid Medline, Scopus, and Web of Science for randomized controlled trials and comparative observational studies from inception to June 2023. Study selection and data extraction were done in duplicate by 2 independent reviewers. We conducted a meta-analysis with random-effects models, and we used GRADE to assess the certainty of evidence at the outcome level. We screened a total of 2,699 studies, and 133 were selected for full-text review. A total of 18 studies, including 12 randomized controlled trials, underwent quantitative analysis. In the meta-analysis of 18 studies (9,151 patients), bougie use was associated with increased first-attempt intubation success (pooled risk ratio [RR] 1.11, 95% confidence interval [CI] 1.06 to 1.17, low certainty evidence). Bougie use was associated with increased first-attempt success across all analyzed subgroups with similar effect estimates, including in emergency intubations (9 studies; 8,070 patients; RR 1.11, 95% CI 1.05 to 1.16, low certainty). The highest point estimate favoring the use of a bougie was in the subgroup of patients with Cormack-Lehane III or IV (5 studies, 585 patients, RR 1.60, 95% CI 1.40 to 1.84, moderate certainty). In this meta-analysis, the bougie as an aid in the first intubation attempt was associated with increased success. Despite the certainty of evidence being low, these data suggest that a bougie should probably be used first and not as a rescue device in emergency intubations.
有人提议使用探条（一种可弯曲的气管插管引导器）来提高急诊科插管首次尝试的成功率。我们旨在评估关于首次尝试使用探条与气管插管成功之间关联的现有证据。这是一项系统评价和荟萃分析，纳入了评估在所有场景下使用探条与不使用探条（通常使用管芯）进行成人插管首次尝试成功率的研究。排除了人体模型和尸体研究。一名医学图书馆员检索了Ovid Cochrane Central、Ovid Embase、Ovid Medline、Scopus和Web of Science，以查找从创刊至2023年6月的随机对照试验和比较观察性研究。研究选择和数据提取由2名独立评审员重复进行。我们采用随机效应模型进行荟萃分析，并使用GRADE评估结局水平证据的确定性。我们共筛选了2699项研究，其中133项被选进行全文评审。共有18项研究（包括12项随机对照试验）进行了定量分析。在对18项研究（9151例患者）的荟萃分析中，使用探条与首次尝试插管成功率增加相关（合并风险比[RR]为1.11，95%置信区间[CI]为1.06至1.17，低确定性证据）。在所有分析的亚组中，使用探条与首次尝试成功率增加相关，效应估计相似，包括在急诊插管中（9项研究；8070例患者；RR为1.11，95%CI为1.05至1.16，低确定性）。支持使用探条的最高点估计值出现在Cormack-Lehane III或IV级患者亚组中（5项研究，585例患者，RR为1.60，95%CI为1.40至1.84，中等确定性）。在这项荟萃分析中，探条作为首次插管尝试的辅助工具与成功率增加相关。尽管证据确定性较低，但这些数据表明在急诊插管中可能应首先使用探条，而不是作为抢救设备。
