Combined videolaryngoscopy and flexible bronchoscopy for difficult tracheal intubation in children: a retrospective observational cohort study.

INTRODUCTION Children with difficult airways are at high risk of complications. Alternative techniques to direct laryngoscopy for tracheal intubation include videolaryngoscopy, flexible bronchoscopy and the hybrid technique of simultaneous videolaryngoscopy and flexible bronchoscopy. This analysis aimed to compare the first-attempt success of each technique and assess the complications associated with difficult paediatric intubations in a quaternary paediatric institution. METHODS The electronic health records of a single quaternary paediatric hospital were searched to identify anaesthesia encounters involving difficult paediatric intubation. This was defined either by the Pediatric Difficult Intubation Registry criteria or as tracheal intubation requiring ≥ 3 attempts. Primary outcomes were the first-attempt success rate and incidence of complications with each tracheal intubation technique. RESULTS From April 2019 to January 2024, 559 encounters involving difficult tracheal intubation were identified. First-attempt success was highest for the hybrid technique (70/94, 74.5%) compared with videolaryngoscopy (143/235, 60.9%, p = 0.020) or direct laryngoscopy (19/190, 10.0%, p < 0.001). The hybrid technique was used to rescue 19/27 (70.4%) encounters where videolaryngoscopy alone was unsuccessful and was successful in all these encounters. Eighty-six (15.4%) encounters had at least one complication. The complication rate was significantly higher for patients weighing < 10 kg (45/184, 24.5%) compared with those weighing ≥ 10 kg (41/375, 10.9%, p < 0.001). The hybrid technique was associated with a lower incidence of complications (5/94, 5.3%) compared with videolaryngoscopy (33/235, 14.0%, p = 0.025) or direct laryngoscopy (41/190, 21.6%, p < 0.001). DISCUSSION In children with difficult tracheal intubation, the hybrid technique was associated with a higher first-attempt success rate compared with videolaryngoscopy alone or direct laryngoscopy. Consideration should be given to the hybrid technique as a first-line approach when difficult tracheal intubation is anticipated and when there is a failed attempt with either direct laryngoscopy or videolaryngoscopy.