Intubation using the gum-elastic bougie while wearing personal protective equipment


  • Nadav Milk, MD
  • Yossi Rosman, MD
  • Nirit Yavnai, DMD, MPH
  • Barak Cohen, MD
  • Nimrod Ophir, MD
  • Arik Eisenkraft, MD, MPH
  • Michael Kassirer, MD



chemical incident, airway control, intubation, bougie, personal protective equipment


Objective: To determine whether application of a gum-elastic bougie (GEB), a visual stylet used to improve success rates of difficult intubations, reduces the time, and number of attempts to achieve successful intubation while wearing personal protective equipment (PPE).

Design: A randomized cross-over study comparing orotracheal intubations performed on an AirMan® Mannequin, using either a semirigid stylet or a GEB, while wearing an active hood with a charcoal impregnated suit and butyl rubber gloves.

Setting: Simulation training field of the Israel Defense Force Medical Corps.

Participants: 27 military physicians and 23 paramedics (PMs).

Interventions: Comparing intubation with and without using the GEB while wearing PPE.

Main outcome measure(s): Airway (AW) control was considered successful if the “lungs” of the mannequin expanded during bag ventilation. Three unsuccessful attempts or a procedure exceeding 60 seconds were regarded as a failure. Correlations between parameters of self-assessment of skills and successful intubation were also determined.

Results: With the GEB, success rate was lower (82 percent versus 100 percent, p = 0.002), more attempts were needed (1.4 ± 0.7 versus 1.0 ± 0.2, p = 0.005) and time-to-achieve AW control was longer (43.6 ± 14.6 seconds versus 23.1 ± 10.5 seconds, P < 0.001) than without it. Participants with high self-assessment of GEB-assisted AW management skills needed less attempts to perform successful intubation with GEB than participants with low self-assessment (1.0 ± 0.0 versus 1.4 ± 0.8, p = 0.001), but not less time to achieve it.

Conclusions: While donning PPE, the use of GEB (versus semirigid stylets) did not reduce the time or the number of attempts necessary to achieve successful intubation.

Author Biographies

Nadav Milk, MD

Israel Defense Forces Medical Corps, Ramat Gan, Israel

Yossi Rosman, MD

Unit of Allergy and Clinical Immunology, Meir Medical Center, Kfar Saba, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

Nirit Yavnai, DMD, MPH

Israel Defense Forces Medical Corps, Ramat Gan, Israel

Barak Cohen, MD

Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio

Nimrod Ophir, MD

Israel Defense Forces Medical Corps, Ramat Gan, Israel

Arik Eisenkraft, MD, MPH

Professor, Faculty of Medicine, Institute for Research in Military Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel

Michael Kassirer, MD

Israel Defense Forces Medical Corps, Ramat Gan, Israel


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How to Cite

Milk, MD, N., Y. Rosman, MD, N. Yavnai, DMD, MPH, B. Cohen, MD, N. Ophir, MD, A. Eisenkraft, MD, MPH, and M. Kassirer, MD. “Intubation Using the Gum-Elastic Bougie While Wearing Personal Protective Equipment”. American Journal of Disaster Medicine, vol. 15, no. 2, Apr. 2020, pp. 85-92, doi:10.5055/ajdm.2020.0358.




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