IMPORTANCEFor critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain.OBJECTIVE To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt. DESIGN, SETTING, AND PARTICIPANTS The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021. INTERVENTIONS Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). MAIN OUTCOMES AND MEASURESThe primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%. RESULTS Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, −2.6 percentage points [95% CI, −7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, −1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group.CONCLUSIONS AND RELEVANCE Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet.

During the COVID19 pandemic, a subset of patients presented with hypoxemia and shock as a complication of SARS-CoV-2 infection. CASE PRESENTATION: A 68-year-old Black male presented with ARDS due to SARS-CoV-2. He had dyspnea and cough for the preceding 6 days. At the time of admission, he developed respiratory failure, was placed on mechanical ventilation, and transferred to our facility for further care. His co-morbidities include diabetes, hypertension treated with an ACE inhibitor, CKD stage III, and obstructive sleep apnea. On arrival, he was afebrile, blood pressure was 117/56 mmHg (mean arterial pressure 75 mmHg) without vasopressor support, oxygen saturation was 85% on 100% FiO2. Exam was significant for diminished breath sounds and trace lower extremity edema. The patient's hemodynamics, renal function, and oxygenation worsened within hours of arrival, prompting use of multiple vasopressors, deep sedation, and paralytic agents. An angiotensin II (AngII) infusion was started due to refractory shock. Within 30 minutes of starting AngII, other vasoactive medications were successfully weaned. Interestingly, oxygenation subsequently improved by 30% (P/F 128 to 168) during this same time period in the absence of other interventions (Figure). The AngII infusion was tapered and the patient did not develop further shock. The patient continues to convalesce. DISCUSSION: The renin-angiotensin-aldosterone system (RAAS) has been implicated in the pathogenesis of COVID-19. The SARS-CoV-2 virus enters tissues through the ACE2 receptor. ACE2 converts AngII into Angiotensin-(1-7) and may offset the effects against vasoconstrictive, inflammatory, and pro-fibrotic responses associated with AngII. Loss of this protective mechanism could be responsible for some of the ventilation/perfusion mismatch observed in ARDS related to COVID-19. CONCLUSIONS: Our patient's brisk hemodynamic and oxygenation response to AngII suggests that alterations to RAAS are relevant in COVID-19, and that this pathway can be therapeutically targeted. These observations merit further investigation.

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