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.