Bougie-First Intubation: What 9,151 Patients Show [Journal Club]

For ten years I treated the bougie as a backup — the break-glass tool, Plan B. Then a 2024 systematic review and meta-analysis in Annals of Emergency Medicine made me reconsider whether it should be my first move on every airway. In this episode of Overheard Journal Club, I break down von Hellmann and colleagues’ pooled analysis of 18 studies and 9,151 patients: the headline 11% relative improvement in first-attempt success, the much larger benefit in difficult airways, and the honest caveats — high heterogeneity, low certainty, and a heavy dependence on operator skill. We also unpack the BEAM versus-BOUGIE plot twist that explains why the same tool can look transformative in one trial and useless in another, and I lay out a practical, four-step way to decide whether the bougie belongs in your hand on attempt number one. Key takeaways •  Across 18 studies and 9,151 patients, bougie use was associated with an 11% relative improvement in first-attempt success (RR 1.11). •  The benefit is much larger in difficult airways — Cormack-Lehane grade 3–4 — where the relative risk hit 1.60. •  Certainty is low and heterogeneity is high; the effectdepends heavily on who is holding the bougie. •  The bougie is a standard-geometry tool — keep direct laryngoscopy plus bougie fluent even if your department defaults to hyper-angulated video laryngoscopy. •  With a standard-geometry blade, consider moving the bougie from backup to first-line — then practice it. Disclaimer This podcast is for educational purposes only. It is not medical advice and does not establish a physician–patient relationship. Always discuss management decisions with a qualified clinician.