<![CDATA[Introduction: Bougie-first and stylet-first techniques are widely used to facilitate adult tracheal intubation, but randomized evidence remains inconsistent across emergency, intensive care, and operating room settings. This systematic review and meta-analysis aimed to compare bougie-first versus stylet-first intubation in adults, focusing on first-attempt intubation success and key procedural and airway-related safety outcomes. Material and Methods: We conducted a PRISMA 2020–compliant systematic review registered in PROSPERO (CRD420261298317). PubMed, Scopus, Web of Science, and Cochrane CENTRAL were searched from database inception to 31 January 2026. Records were screened in duplicate, and randomized controlled trials enrolling adults (≥18 years) undergoing oral tracheal intubation comparing a planned bougie-first strategy versus a planned stylet-first strategy were included. Random-effects meta-analyses pooled dichotomous outcomes as odds ratios (ORs) and continuous outcomes as mean differences (MDs). Results: From 1,158 records, eight randomized controlled trials involving 2,578 participants were included. First-attempt intubation success did not differ significantly between bougie-first and stylet-first techniques (OR 0.99, 95% CI 0.37–2.65; p = 0.980), with substantial heterogeneity (I² = 89.05%; p < 0.001). Bougie-first was associated with longer time to successful intubation (MD 21.84 seconds, 95% CI 5.55–38.14; p = 0.010), although heterogeneity was very high (I² = 97.37%; p < 0.001). There were no significant differences in more than one attempt (OR 0.91, 95% CI 0.21–3.91; p = 0.900), esophageal intubation (OR 0.48, 95% CI 0.17–1.40; p = 0.180), pulmonary aspiration (OR 1.47, 95% CI 0.57–3.75; p = 0.420), or postoperative sore throat (OR 1.10, 95% CI 0.48–2.52; p = 0.830). Conclusion: Current randomized evidence did not demonstrate a consistent difference in first-attempt intubation success between bougie-first and styletfirst tracheal intubation in adults. Bougie-first was associated with longer intubation time, but this finding should be interpreted cautiously because of very high heterogeneity and variable timing definitions. ]]>
