Videolaryngoscopy versus fiberoptic bronchoscopy for awake  tracheal intubation. Systematic review and meta-analysis

Jorge Fernández; Manuel Taboada; María Bermúdez; Borja Cardalda-Serantes; Paula López Cao; Julián Álvarez; Teresa Seoane-Pillado

doi:10.5554/22562087.e1164

Jorge Fernández Anesthesia and Resuscitation Service, Complejo Hospitalario Universitario de Santiago de Compostela. Santiago de Compostela, Spain. https://orcid.org/0000-0003-4510-3137
Manuel Taboada Anesthesia and Resuscitation Service, Complejo Hospitalario Universitario de Santiago de Compostela. Santiago de Compostela, Spain. https://orcid.org/0000-0003-4627-0287
María Bermúdez Anesthesia and Resuscitation Service, Complejo Hospitalario Universitario Lucus Augusti de Lugo. Lugo, Spain. https://orcid.org/0000-0003-0853-1300
Borja Cardalda-Serantes Anesthesia and Resuscitation Service, Complejo Hospitalario Universitario de Santiago de Compostela. Santiago de Compostela, Spain. https://orcid.org/0009-0000-9199-8336
Paula López Cao Medicine, Universidad de Santiago de Compostela. Santiago de Compostela, Spain. https://orcid.org/0009-0006-8465-0044
Julián Álvarez Anesthesia and Resuscitation Service, Complejo Hospitalario Universitario de Santiago de Compostela. Santiago de Compostela, Spain.
Teresa Seoane-Pillado Health Sciences Department. Public Health and Preventive Medicine Unit, Universidad de A Coruña (INIBIC). A Coruña, Spain. https://orcid.org/0000-0002-8091-9791

DOI: https://doi.org/10.5554/22562087.e1164

Keywords: Awake tracheal intubation, Videolaryngoscopy, Fiberoptic bronchoscopy, Difficult airway, Airway management, Meta-analysis, Sistematic review

Abstract References How to Cite Downloads

Abstract

Introduction: All of the international guidelines and consensus documents recommend managing the difficult airway while maintaining spontaneous breathing during tracheal intubation. Currently, the safest and most widely used techniques are flexible bronchoscopy and videolaryngoscopy.

Objective: The aim of this systematic review and meta-analysis was to compare videolaryngoscopy (VL) versus fiberoptic bronchoscopy (FB) for ATI (ATI).

Methods: A systematic search of randomized clinical trials was conducted in PubMed, Web of Science and CENTRAL, following the PRISMA guidelines. The Cochrane RoB2 tool was used to analyze risk of bias. A random effects model was used and heterogeneity was quantified by means of the I2 test.

Results: Of 1,254 entries retrieved, 11 met the inclusion criteria for review and 10 were included in the meta-analysis (593 patients). There were no significant differences between the two intubation techniques on first attempt (9 studies, 576 patients, risk ratio [RR] [95% CI] 1.00 [0.95-1.06]), or in terms of intubation success (9 studies, 539 patients, RR [95% CI] 0.99 [0.97-1.02]). VL was associated with shorter intubation time (10 studies, 580 patients, mean [95% CI] -50.39 [-82.0–18.8] seconds) and a lower incidence of hypoxia (7 studies, 461 patients, RR [IC95 %] 0.48 [0.24-0.98]). There were no differences regarding the incidence of other complications.

Conclusions: VL and FB for awake intubation are equally effective in terms of intubation on first attempt and overall success of the technique. VL was associated with a shorter intubation time and a lower incidence of hypoxia.

References

1. 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. https://doi.org/10.1097/ALN.0000000000004002.

2. Ahmad I, El-Boghdadly K, Bhagrath R, Hodzovic I, McNarry AF, Mir F, et al. Difficult Airway Society guidelines for ATI (ATI) in adults. Anaesthesia. 2020;75(4):509-28. https://doi.org/10.1111/anae.14904.

3. Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances R, et al. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Rev Esp Anestesiol Reanim (Engl Ed). 2024;71(3):171-206. https://doi.org/10.1016/j.redare.2024.02.001.

4. Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances R, et al. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. Rev Esp Anestesiol Reanim (Engl Ed). 2024;71(3):207-47. https://doi.org/10.1016/j.redare.2024.02.002.

5. Fitzgerald E, Hodzovic I, Smith AF. 'From darkness into light': time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia. 2015;70(4):387-92. https://doi.org/10.1111/anae.

6. Moore A, Schricker T. Awake videolaryngoscopy versus fiberoptic bronchoscopy. Curr Opin Anaesthesiol. 2019;32(6):764-8. https://doi.org/10.1097/ACO.0000000000000771.

7. Wilson WM, Smith AF. The emerging role of awake videolaryngoscopy in airway management. Anaesthesia. 2018;73(9):1058-61. https://doi.org/10.1111/anae.14324.

8. Markova L, Stopar-Pintaric T, Luzar T, Benedik J, Hodzovic I. A feasibility study of awake videolaryngoscope-assisted intubation in patients with periglottic tumour using the channelled King Vision® videolaryngoscope. Anaesthesia. 2017;72(4):512-8. https://doi.org/10.1111/anae.13734.

9. Johnson DM, From AM, Smith RB, From RP, Maktabi MA. Endoscopic study of mechanisms of failure of endotracheal tube advancement into the trachea during awake fiberoptic orotracheal intubation. Anesthesiology. 2005;102(5):910-4. https://doi.org/10.1097/00000542-200505000-00008.

10. Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions. Br J Anaesth. 2004;92(6):870-81. https://doi.org/10.1093/bja/aeh136.

11. Ho AM, Chung DC, To EW, Karmakar MK. Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway. Can J Anaesth. 2004;51(8):838-41. https://doi.org/10.1007/BF03018461.

12. Gupta D, Wang H. Cost-effectiveness analysis of flexible optical scopes for tracheal intubation: a descriptive comparative study of reusable and single-use scopes. J Clin Anesth. 2011;23(8):632-5. https://doi.org/10.1016/j.jclinane.2011.04.007.

13. Heidegger T, Gerig HJ, Ulrich B, Schnider TW. Structure and process quality illustrated by fibreoptic intubation: analysis of 1612 cases. Anaesthesia. 2003;58(8):734-9. https://doi.org/10.1046/j.1365-2044.2003.03200.x.

14. Ray DC, Billington C, Kearns PK, Kirkbride R, Mackintosh K, Reeve CS, et al. A comparison of McGrath and Macintosh laryngoscopes in novice users: a manikin study. Anaesthesia. 2009;64(11):1207-10. https://doi.org/10.1111/j.1365-2044.2009.06061.x.

15. Alhomary M, Ramadan E, Curran E, Walsh SR. Videolaryngoscopy vs.. fibreoptic bronchoscopy for ATI: a systematic review and meta-analysis. Anaesthesia. 2018;73(9):1151-61. https://doi.org/10.1111/anae.14299.

16. Jiang J, Ma DX, Li B, Wu AS, Xue FS. Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation - a systematic review and meta-analysis of randomized controlled trials. Ther Clin Risk Manag. 2018;14:1955-63. https://doi.org/10.2147/TCRM.S172783.

17. Desai N, Ratnayake G, Onwochei DN, El-Boghdadly K, Ahmad I. Airway devices for ATI in adults: a systematic review and network meta-analysis. Br J Anaesth. 2021;127:636-47. https://doi.org/10.1016/j.bja.2021.05.025.

18. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372(71). https://doi.org/10.1136/bmj.n71.

19. Luo D, Wan X, Liu J, Tong T. Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range. Stat Methods Med Res. 2018;27(6):1785-805. https://doi.org/10.1177/0962280216669183.

20. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135. https://doi.org/10.1186/1471-2288-14-135.

21. Higgins JPT, Savović J, Page MJ, Elbers RG, Sterne JAC. Chapter 8: Assessing risk of bias in a randomized trial. En: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editores). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023.

22. Cohn AI, Zornow MH. Awake endotracheal intubation in patients with cervical spine disease: a comparison of the Bullard laryngoscope and the fiberoptic bronchoscope. Anesth Analg. 1995;81(6):1283-6. https://doi.org/10.1097/00000539-199512000-00027.

23. Rosenstock CV, Thogersen B, Afshari A, Christensen AL, Eriksen C, Gatke MR. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trial. Anesthesiology. 2012;116:1210-6. https://doi.org/10.1097/ALN.0b013e318254d085.

24. Wahba SSTT, Saeed AM. Comparative study of awake endotracheal intubation with Glidescope video laryngoscope vs.. flexible fiber optic bronchoscope in patients with traumatic cervical spine injury. Egypt J Anaesth. 2012;28:257-60. https://doi.org/10.1016/j.egja.2012.05.002.

25. Abdellatif AA, Ali MA. GlideScope videolaryngoscope vs.. flexible fiberoptic bronchoscope for awake intubation of morbidly obese patient with predicted difficult intubation. Middle East J Anesthesiol. 2014;22:385-92.

26. Kramer A, Muller D, Pfortner R, Mohr C, Groeben H. Fibreoptic vs. videolaryngoscopic (C-MAC((R)) D-BLADE) nasal awake intubation under local anaesthesia. Anaesthesia. 2015;70:400-6. https://doi.org/10.1111/anae.13016.

27. Mendonca C, Mesbah A, Velayudhan A, Danha R. A randomised clinical trial comparing the flexible fibrescope and the Pentax Airway Scope (AWS)((R)) for awake oral tracheal intubation. Anaesthesia. 2016;71:908-14. https://doi.org/10.1111/anae.13516.

28. Moore A, El-Bahrawy A, El-Mouallem E, et al. Videolaryngoscopy or fibreoptic bronchoscopy for awake intubation of bariatric patients with predicted difficult airways – a randomised, controlled trial. Anaesthesia. 2017;72:538-9. https://doi.org/10.1111/anae.13850.

29. Mahran EA, Hassan ME. Comparative randomised study of GlideScope(R) video laryngoscope vs.. flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubation. Indian J Anaesth. 2016;60:936-8. https://doi.org/10.4103/0019-5049.195487.

30. Hegazy, A, Al-Kawally H, Ismail EF, Abedlmabood MA, Mandour UA. Comparison between fiberoptic bronchoscope versus C-MAC video-laryngoscope for awake intubation in obese patients with predicted difficult airway. Res Opin Anesth Intens Care. 2018;5:134-40. https://doi.org/10.4103/roaic.roaic_28_17.

31. Kamga H, Frugier A, Boutros M, Bourges J, Doublet T, Parienti JJ. Flexible nasal bronchoscopy vs.. Airtraq® videolaryngoscopy for ATI: a randomised controlled non-inferiority study. Anaesthesia. 2023;78:963-9. https://doi.org/10.1111/anae.16042.

32. Dutta K, Sriganesh K, Chakrabarti D, Pruthi N, Reddy M. Cervical spine movement during awake orotracheal intubation with Fiberoptic Scope and McGrath videolaryngoscope in patients undergoing surgery for cervical spine instability: A randomized control trial. J Neurosurg Anesthesiol. 2020;32:249-55. https://doi.org/10.1097/ANA.0000000000000595.

33. Ho AM, Chung DC, Karmakar MK, Gomersall CD, Peng Z, Tay BA. Dynamic airflow limitation after topical anaesthesia of the upper airway. Anaesth Intensive Care. 2006;34(2):211-5. https://doi.org/10.1177/0310057X0603400207.

34. Taboada M, Fernández J, Estany-Gestal A. A randomised comparison between a hyperangulated unchannelled videolaryngoscope (C-MAC® D-Blade) and a channelled videolaryngoscope (Airtraq®) for intubation in awake patients with anticipated difficult airway. Anaesthesia. 2024;79(11):1157-64. https://doi.org/10.1111/anae.16389.

35. Kleine-Brueggeney M, Greif R, Schoettker P, Savoldelli GL, Nabecker S, Theiler LG. Evaluation of six videolaryngoscopes in 720 patients with a simulated difficult airway: a multicentre randomized controlled trial. Br J Anaesth. 2016;116:670-9. https://doi.org/10.1093/bja/aew058.

How to Cite

1.

Fernández J, Taboada M, Bermúdez M, Cardalda-Serantes B, López Cao P, Álvarez J, et al. Videolaryngoscopy versus fiberoptic bronchoscopy for awake tracheal intubation. Systematic review and meta-analysis. Colomb. J. Anesthesiol. [Internet]. 2025 Jul. 30 [cited 2026 Jan. 17];53(4). Available from: https://www.revcolanest.com.co/index.php/rca/article/view/1164