Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation: a systematic review and meta‐analysis

Abstract

SummaryAwake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. However, videolaryngoscopes are being used more commonly. We searched the current literature and performed a meta-analysis to compare the use of videolaryngoscopy and fibreoptic bronchoscopy for awake tracheal intubation. Our primary outcome was the time needed to intubate the patient's trachea. Secondary outcomes included: failed intubation; the rate of successful intubation at the first attempt; patient-reported satisfaction with the technique; and any complications resulting from intubation. Eight studies examining 429 patients were included in this review. The intubation time was shorter when videolaryngoscopy was used instead of fibreoptic bronchoscopy (seven trials, 408 participants, mean difference (95%CI) À45.7 (À66.0 to À25.4) s, p < 0.0001, low-quality evidence). There was no significant difference between the two techniques in the failure rate (six studies, 355 participants, risk ratio (95%CI) 1.01 (0.24-4.35), p = 0.99, low-quality evidence) or the first-attempt success rate (six studies, 391 participants, risk ratio (95%CI) 1.01 (0.95-1.06), p = 0.8, moderate quality evidence). The level of patient satisfaction was similar between both groups. No difference was found in two reported adverse events: hoarseness/sore throat (three studies, 167 participants, risk ratio (95%CI) 1.07 (0.62-1.85), p = 0.81, low-quality evidence), and low oxygen saturation (five studies, 337 participants, risk ratio (95%CI) 0.49 (0.22-1.12), p = 0.09, low-quality evidence). In summary, videolaryngoscopy for awake tracheal intubation is associated with a shorter intubation time. It also seems to have a success rate and safety profile comparable to fibreoptic bronchoscopy.

Experience in awake fibreoptic intubation: a reply

“…Hence, training in awake VL will lend itself well to awake FB training. Additionally, there have been calls for awake VL to become a core anaesthetic skill [2] as a recent meta-analysis demonstrated a similar success rate and safety profile compared with FB [3], and we support the notion that more of these should be incorporated into training. Obtaining and maintaining competence in the procedural skill of awake VL is readily achievable, as the technique is more similar to the asleep approach than FB and therefore more readily practiced.…”

Randomized comparison of McGrath MAC videolaryngoscope, Pentax Airway Scope, and Macintosh direct laryngoscope for nasotracheal intubation in patients with manual in-line stabilization

“…18 In addition, various VLs can be used during awake intubation. 30 This study is helpful because it explores the usefulness of various types of VLs in nasotracheal intubation with simulated difficult airway situations.…”

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

“…Awake tracheal intubation has a favourable safety profile because both spontaneous ventilation and intrinsic airway tone are maintained until the trachea is intubated [31][32][33][34][35]. Awake tracheal intubation can be unsuccessful in 1-2% of cases, but this rarely leads to airway rescue strategies or death [33][34][35].…”

“…among experts demonstrating superiority of one route if both are feasible[33-35, 64, 71].Awake tracheal intubation using videolaryngoscopy has a comparable success rate and safety profile to ATI:FB (98.3% each)[31]. Choosing between techniques is based on patient factors, operator skills and availability of equipment (Grade A).…”