Emergency airway management with the gum elastic bougie outside of the operating room: a narrative review

The ongoing coronavirus 2019 (COVID-19) pandemic has increased the need for healthcare professionals to perform emergency endotracheal intubation (ETI) in patients with COVID-19-related respiratory failure outside of the operating room. Difficult airways and severe airway-related adverse events occur much more frequently in such settings due to limited time and resources as well as the patient’s reduced physiological reserve. The gum elastic bougie (GEB) intubation tube is an inexpensive, simple, and readily transportable aid to intubation, but its effectiveness in emergency airway management has not been comprehensively evaluated in recent years. Here, we performed a literature review and have updated the available evidence on the utility of GEB in emergency airway management. After a systematic MEDLINE search, we identified 36 relevant reports that compared GEB with alternative airway management approaches in a variety of real-world and simulated settings. In most studies, GEB increased the first-pass ETI success rate and decreased the force applied on the tongue and incisors during laryngoscopy. GEB also increased the speed, safety, and reliability of emergency cricothyrotomy. Conflicting results were obtained in studies examining GEB use for ETI during cardiopulmonary resuscitation, and other special circumstances such as selective lung ventilation, the presence of vomitus, and the use of personal protective equipment. These results suggest that GEB use could be expanded beyond difficult airways and rescue after failed ETI attempts, but further studies will be necessary to determine the utility of GEB under special conditions. Because fatal airway-related adverse events can in part be attributed to limited accessibility of proper airway management equipment, devices such as GEB may increase successful outcomes, especially under the overwhelmingly challenging conditions imposed by the COVID-19 pandemic.