Use of combined laryngo-bronchoscopy intubation approach in a simulated difficult airway scenario with cervical stabilization

The occurrence of unexpected difficult airway management (DAM) during endotracheal intubation (ETI) attempts represents a life-threatening scenario. The management of such challenges may improve with training in simulated DAM scenarios. Moreover, simulation allows investigation at the potential value of new devices and techniques for DAM. The combined use of laryngoscopy with fiberoptic bronchoscope (CLBI) has been proposed in this regard, but its performance by novices facing DAM remain unexplored. We performed a randomized crossover simulation study evaluating the performance of ninety-six anesthesiology residents during ETI with four approaches: direct laryngoscopy (DL), Glidescope®, McGrath® and CLBI. Increased difficulty was produced by placement of a cervical collar. Residents had maximum of 3 attempts per device/technique (up to 60 seconds per attempt). The main outcomes were success rate (SR) and corrected time-to-intubation (cTTI, with 60 seconds added for each failed attempt). Subgroup analyses were performed separating residents according to their experience (junior, n = 60; senior, n = 36).The CLBI had significantly lower SR at both 1st and 3rd attempt (31% and 64%, respectively) as compared to DL (93% and 98%), Glidescope® (70% and 86%) and McGrath® (58% and 84%), with all p < 0.001. Moreover, CLBI had significantly longer cTTI (158.5 seconds; (54.3; 180)) than other devices: Glidescope® (37.6 seconds; (24.7; 88.2)), McGrath® (39.3 seconds; (20.6; 105.1)), and DL (19 seconds; (15.4; 27.2)), all p < 0.002. CLBI and McGrath® were the only approaches performing better in senior as compared to junior residents. In a DAM simulated setting, anesthesiology residents had lower SR and longer cTTI with the CLBI as compared to direct and video-laryngoscopy.

Direct laryngoscopy; Endotracheal intubation; Fiberoptic bronchoscope; Manikin; Simulation; Video-laryngoscopy

[1] Santou N, Ueta H, Nakagawa K, Hata K, Kusunoki S, Sadamori T, et al. A comparative study of video laryngoscope vs. Macintosh laryngoscope for prehospital tracheal intubation in Hiroshima, Japan. Resuscitation Plus. 2023; 13: 100340.

[2] Liti A, Giusti GD, Gili A, Giontella M, Dell’Omo S, Camerlingo V, et al. Insertion of four different types of supraglottic airway devices by emergency nurses. A mannequin-based simulation study. Acta Biomedica. 2020; 91: e2020016.

[3] Pourmand A, Terrebonne E, Gerber S, Shipley J, Tran QK. Efficacy of video laryngoscopy versus direct laryngoscopy in the prehospital setting: a systematic review and meta-analysis. Prehospital and Disaster Medicine. 2023; 38: 111–121.

[4] Anderson J, Ebeid A, Stallwood-Hall C. Pre-hospital tracheal intubation in severe traumatic brain injury: a systematic review and meta-analysis. British Journal of Anaesthesia. 2022; 129: 977–984.

[5] Galinski M, Wrobel M, Boyer R, Reuter PG, Ruscev M, Debaty G, et al. Risk factors for failed first intubation attempt in an out-of-hospital setting: a multicenter prospective study. Internal and Emergency Medicine. 2023; 18: 265–272.

[6] Ko JI, Ha SO, Koo MS, Kwon M, Kim J, Jeon J, et al. Comparison of intubation times using a manikin with an immobilized cervical spine: Macintosh laryngoscope vs. GlideScope vs. fiberoptic bronchoscope. Clinical and Experimental Emergency Medicine. 2015; 2: 244–249.

[7] Bogdański Ł, Truszewski Z, Kurowski A, Czyżewski Ł, Zaśko P, Adam-czyk P, et al. Simulated endotracheal intubation of a patient with cervical spine immobilization during resuscitation: a randomized comparison of the Pentax AWS, the Airtraq, and the McCoy Laryngoscopes. The American Journal of Emergency Medicine. 2015; 33: 1814–1817.

[8] Goutcher CM, Lochhead V. Reduction in mouth opening with semi-rigid cervical collars. British Journal of Anaesthesia. 2005; 95: 344–348.

[9] Wakeling HG, Nightingale J. The intubating laryngeal mask airway does not facilitate tracheal intubation in the presence of a neck collar in simulated trauma. British Journal of Anaesthesia. 2000; 84: 254–256.

[10] Komatsu R, Nagata O, Kamata K, Yamagata K, Sessler DI, Ozaki M. Intubating laryngeal mask airway allows tracheal intubation when the cervical spine is immobilized by a rigid collar. British Journal of Anaesthesia. 2004; 93: 655–659.

[11] Kumar A, Taluja A, Saxena B, Dwivedi P. A comparative evaluation of 2 videolaryngoscopes as an intubation aid in a simulated difficult airway: a prospective randomised study. Turkish Journal of Anaesthesiology & Reanimation. 2022; 50: 340–345.

[12] Jepsen CH, Gätke MR, Thøgersen B, Mollerup LT, Ruhnau B, Rewers M, et al. Tracheal intubation with a flexible fibreoptic scope or the McGrath videolaryngoscope in simulated difficult airway scenarios. European Journal of Anaesthesiology. 2014; 31: 131–136.

[13] Rothkrug A, Mahboobi SK. Simulation training and skill assessment in anesthesiology. StatPearls: Treasure Island (FL). 2022.

[14] Ruetzler K, Imach S, Weiss M, Haas T, Schmidt AR. Comparison of five video laryngoscopes and conventional direct laryngoscopy: investigations on simple and simulated difficult airways on the intubation trainer. Anaesthesist. 2015; 64: 513–519. (In German)

[15] Sulser S, Ubmann D, Schlaepfer M, Brueesch M, Goliasch G, Seifert B, et al. C-MAC videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department. European Journal of Anaesthesiology. 2016; 33: 943–948.

[16] Malik MA, Maharaj CH, Harte BH, Laffey JG. Comparison of Macintosh, Truview EVO2®, Glidescope®, and Airwayscope® laryngoscope use in patients with cervical spine immobilization. British Journal of Anaesthesia. 2008; 101: 723–730.

[17] Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber J. Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study. European Journal of Anaesthesiology. 2009; 26: 554–558.

[18] Maharaj CH, McDonnell JG, Harte BH, Laffey JG. A comparison of direct and indirect laryngoscopes and the ILMA in novice users: a manikin study. Anaesthesia. 2007; 62: 1161–1166.

[19] Park J, An S, Park S, Nahm FS, Han S, Kim J. Comparison of a new video intubation stylet and McGrath® MAC video laryngoscope for intubation in an airway manikin with normal airway and cervical spine immobilization scenarios by novice personnel: a randomized crossover study. BioMed Research International. 2021; 2021: 4288367.

[20] Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American society of anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022; 136: 31–81.

[21] Sanfilippo F, Chiaramonte G, Sgalambro F. Video laryngoscopes and best rescue strategy for unexpected difficult airways: do not forget a combined approach with flexible bronchoscopy! Anesthesiology. 2017; 126: 1203–1203.

[22] Sgalambro F, Sanfilippo F, Santonocito C, Caltavuturo C, Grillo C. Virtual laryngoscopy and combined laryngoscopic-bronchoscopic approach for safe management of obstructive upper airways lesions. British Journal of Anaesthesia. 2014; 113: 304–306.

[23] Nedrud SM, Baasch DG, Cabral JD, McEwen DS, Dasika J. Combined video laryngoscope and fiberoptic nasal intubation. Cureus. 2021; 13: e19482.

[24] Yukihiro I, Komasawa N, Fujiwara S, Tsuji E, Minami T. Efficacy of a bronchofiberscope in combination with the GlideScopee in a difficult airway patient. SAGE Open Medical Case Reports. 2016; 65: 1013–1015.(In Japanese)

[25] Sowers N, Kovacs G. Use of a flexible intubating scope in combination with a channeled video laryngoscope for managing a difficult airway in the emergency department. The Journal of Emergency Medicine. 2016; 50: 315–319.

[26] Nishikawa K, Hukuoka E, Kawagishi T, Shimodate Y, Yamakage M. Efficacy of the Airtraq® laryngoscope with a fiberoptic bronchoscope compared with that of Airtraq® alone for tracheal intubation: a manikin study. Journal of Anesthesia. 2011; 25: 93–97.

[27] Sanfilippo F, Sgalambro F, Chiaramonte G, Santonocito C, Burgio G, Arcadipane A. Use of a combined laryngo-bronchoscopy approach in difficult airways management: a pilot simulation study. Turkish Journal of Anaesthesiology & Reanimation. 2019; 47: 464–470.

[28] Cormack RS. Cormack-Lehane classification revisited. British Journal of Anaesthesia. 2010; 105: 867–868.

[29] Levitan RM, Ochroch EA, Rush S, Shofer FS, Hollander JE. Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale. Academic Emergency Medicine. 1998; 5: 919–923.

[30] Komiya K, Inagawa G, Nakamura K, Kikuchi T, Fujimoto J, Sugawara Y, et al. A simple fibreoptic assisted laryngoscope for paediatric difficult intubation: a manikin study. Anaesthesia. 2009; 64: 425–429.

[31] Vlatten A, Aucoin S, Litz S, MacManus B, Soder C. A comparison of bon-fils fiberscope-assisted laryngoscopy and standard direct laryngoscopy in simulated difficult pediatric intubation: a manikin study. Pediatric Anesthesia. 2010; 20: 559–565.

[32] Kovacs G, Law JA, McCrossin C, Vu M, Leblanc D, Gao J. A comparison of a fiberoptic stylet and a bougie as adjuncts to direct laryngoscopy in a manikin-simulated difficult airway. Annals of Emergency Medicine. 2007; 50: 676–685.

[33] Durga P, Kaur J, Ahmed SY, Kaniti G, Ramachandran G. Comparison of tracheal intubation using the Airtraq® and Mc Coy laryngoscope in the presence of rigid cervical collar simulating cervical immobilisation for traumatic cervical spine injury. Indian Journal of Anaesthesia. 2012; 56: 529–534.

[34] Gawlowski P, Smereka J, Madziala M, Cohen B, Ruetzler K, Szarpak L. Comparison of the ETView Single Lumen and Macintosh laryngoscopes for endotracheal intubation in an airway manikin with immobilized cervical spine by novice paramedics. Medicine. 2017; 96: e5873.

[35] Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber JL. Comparison of the Glidescope®, the McGrath®, the Airtraq® and the Macintosh laryngoscopes in simulated difficult airways*. Anaesthesia. 2008; 63: 1358–1364.

[36] Saito T, Asai T, Arai T, Tachikawa M, Shimazaki M, Okuda Y. Efficacy of Coopdech videolaryngoscope: comparisons with a Macintosh laryngoscope and the airway scope in a manikin with difficult airways. Journal of Anesthesia. 2012; 26: 617–620.

[37] Eismann H, Sieg L, Etti N, Friedrich L, Schröter C, Mommsen P, et al. Improved success rates using videolaryngoscopy in unexperienced users: a randomized crossover study in airway manikins. European Journal of Medical Research. 2017; 22: 27.

[38] Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education. Critical Care Medicine. 2014; 42: 169–178.

[39] Rendeki S, Keresztes D, Woth G, Mérei Á, Rozanovic M, Rendeki M, et al. Comparison of VividTrac®, Airtraq®, King Vision®, Macintosh laryngoscope and a custom-made videolaryngoscope for difficult and normal airways in mannequins by novices. BMC Anesthesiology. 2017; 17: 68.

[40] Yi IK, Kwak HJ, Lee KC, Lee JH, Min SK, Kim JY. Comparison of McGrath, Pentax, and Macintosh laryngoscope in normal and cervical immobilized manikin by novices: a randomized crossover trial. European Journal of Medical Research. 2020; 25: 35.

[41] Sanfilippo F, Messina S, Merola F, Tigano S, Morgana A, Dimagli A, et al. Endotracheal intubation during chest compressions in the pediatric simulation setting: a systematic review and meta-analysis. Signa Vitae. 2022; 18: 94–102.

[42] Hung WT, Yang MW, Lin CY. Evaluation of learning effectiveness in endotracheal intubation by the use of a laryngoscope in combination with a flexible fiberoptic bronchoscope. Acta Anaesthesiologica Sinica. 2001; 39: 129–133.

[43] Doleman B, Blackwell J, Karangizi A, Butt W, Bhalla A, Lund JN, et al. Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation. Acta Anaesthesiologica Scandinavica. 2016; 60: 910–916.

[44] Schebesta K, Hüpfl M, Ringl H, Machata A, Chiari A, Kimberger O. A comparison of paediatric airway anatomy with the SimBaby high-fidelity patient simulator. Resuscitation. 2011; 82: 468–472.

[45] Schebesta K, Hüpfl M, Rössler B, Ringl H, Müller M, Kimberger O. Degrees of reality. Anesthesiology. 2012; 116: 1204–1209.

[46] Blackburn MB, Wang SC, Ross BE, Holcombe SA, Kempski KM, Blackburn AN, et al. Anatomic accuracy of airway training manikins compared with humans. Anaesthesia. 2021; 76: 366–372.