Bougie guided versus Endotracheal tube with Stylet guided intubation in critically injured patients with Difficult airway characteristics (BEST trial): randomised clinical trial

Emergency airway management in critically injured trauma patients is frequently complicated by distorted anatomy, airway contamination, cervical spine immobilisation, and prior airway manipulation. Although bougie and stylet are commonly used adjuncts for tracheal intubation, evidence comparing their effectiveness in difficult trauma airways remains limited. We aimed to compare first-pass intubation success between bougie-guided and stylet-guided tracheal intubation in critically injured trauma patients with predefined difficult airway characteristics. In this prospective randomised clinical trial, 188 adult critically injured trauma patients requiring emergency tracheal intubation and having at least one predefined difficult airway characteristic were randomised to bougie-guided intubation (Group B, n = 94) or stylet-guided intubation (Group S, n = 94). All first-attempt intubations were performed by trauma anaesthesia senior residents using video laryngoscopy and a standardised drug-assisted delayed sequence intubation protocol. The primary outcome was first-pass intubation success. Secondary outcomes included time to intubation, rescue airway interventions, need for alternate adjunct or front-of-neck access, and peri-intubation complications. First-pass intubation success was achieved in 67 of 94 patients (71.3%) in Group B and 63 of 94 patients (67.0%) in Group S, corresponding to an absolute difference of 4.3% points (95% CI, − 8.9 to 17.2; p = 0.53). Time to successful first-attempt intubation was similar between groups (39.55 ± 11.72 s in Group B versus 37.97 ± 13.54 s in Group S; mean difference 1.58 s, 95% CI − 2.80 to 5.97; p = 0.48). Emergency front-of-neck access was required in one patient in Group B. Oesophageal intubation occurred in five patients (5.3%) in Group S and in none in Group B; this difference did not reach statistical significance using Fisher’s exact test ( p = 0.059). On multivariable logistic regression, polytrauma with facial fractures was associated with increased odds of first-pass intubation failure (adjusted OR 2.54, 95% CI 1.10–5.83; p = 0.028). In selected trauma patients with predefined difficult-airway characteristics undergoing protocolised delayed sequence intubation with video laryngoscopy, no statistically significant difference in first-pass success was observed between bougie-guided and stylet-guided intubation. Oesophageal intubation occurred only in the stylet group, an exploratory finding that requires confirmation in larger studies. The trial was approved by the Institute Ethics Committee (IEC-INT-2022/MD-543) and registered with the Clinical Trials Registry of India (CTRI/2022/11/047043).