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Rev Esp Anestesiol Reanim. 2016;63(4):189---191

Revista Espaola de Anestesiologa


y Reanimacin
www.elsevier.es/redar

EDITORIAL ARTICLE

Can beroptic bronchoscopy be replaced by video


laryngoscopy in the management of difcult airway?
Puede la vdeo laringoscopia reemplazar a la brobroncoscopia en el
abordaje de la va area difcil?
M.. Gmez-Ros a,b
a

Department of Anaesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coru


na, A Coru
na, Spain
Head of the Anaesthesiology and Pain Management Research Group, Institute for Biomedical Research of A Coru
na (INIBIC),
A Coru
na, Spain

Airway management is a critical competence in anesthesiology. The rst goal in any anesthetic procedure is
to maintain airway patency, ensure the ventilation and
patients oxygenation.1 The incidence of failed intubation,
impossible ventilation, and the cannot intubate, cannot
ventilate scenario range up to 7.5%, 0.15% and 0.007%,
respectively.2,3 Apparently these rates are low, however
they affect to thousands or millions of people worldwide.
Thus, the inability to successfully manage a difcult airway (DA) is responsible for 600 deaths annually and 30%
of deaths attributable to anesthesia.4,5 Therefore airway
throughout history has been and should be treated as a
problem to be solved. The introduction of beroptic bronchoscopy (FOB) and video laryngoscopy constitute two major
milestones in the airway management. A considerable technological evolution has happened from the rst design of
exible bronchoscope of Shigeto Ikeda (1966) to the current video endoscopes. FOB is universally recognized as
method for endotracheal intubation. Its popularity is due
to innate features that are not available in any other device
(Table 1).6 These unique properties allow the greatest success of any nonsurgical technique for DA management with
intubation rates of up to 99% and higher.7,8 It is necessary to
meet several conditions to optimize its features9 (Table 2)
and to be aware of their limitations,1 fortunately all salvageable: (1) cost, fragility-maintenance and possibility
of transmission of infectious diseases. Video endoscopes

E-mail address: magoris@hotmail.com

have greater robustness, and disposable video endoscopes


reduce costs and avoid cross contamination; (2) demanding learning. Andranik Ovassapian asserted that 50 beroptic
intubations (FOI) are needed to acquire competence and 100
to acquire expert level, however several clinical trials have
determined that the learning curve is smaller than previously thought, being necessary 15 cases to obtain a successfull rate of 100%10,11 ; (3) extensive runtime. An expert can
perform intubations in 30 s. Different clinical trials found no
signicant differences in intubation times when comparing
the FOB with a video laryngoscope as Glidescope12---14 ; (4)
advancement of the ETT is entirely blind. The combined use
with a video laryngoscope allows visualizing the passage of
the ETT through the glottis. In case of difculty of threading
the tube this can be solved by reducing the gap size differences between the FOB and the ETT or using an intubation
catheter as Aintree catheter15 ; (5) emerging scenario (presence of secretions, blood, compromised ventilation). The
combined use with ILMA can ensure ventilation and isolate
the airway of secretions or blood in an emergent context.16
FOI is universally recognized as the gold standard in
the awake intubation of predicted DA since the early
80s.6 Thus, it resides worldwide within all airway management guidelines and algorithms,17 and while there are
no evidence-based standards,18 if algorithms and guidelines of different anesthesiology societies are reviewed
it is possible to draw two conclusions,1 (1) FOI is universally recognized as the gold standard in the awake,
sedated, or anesthetized difcult to intubate patient and
(2) almost all guides include it as alternative technique in

http://dx.doi.org/10.1016/j.redar.2015.11.008
0034-9356/ 2015 Sociedad Espa
nola de Anestesiologa, Reanimacin y Teraputica del Dolor. Published by Elsevier Espaa, S.L.U. All rights
reserved.

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190
Table 1

M.. Gmez-Ros
Characteristics of beroptic bronchoscope.

Reduced size and exibility


Two alternative approaches: orotracheal/nasotracheal
intubation
Intubation in extreme situations
Most accurate conrmation of endotracheal intubation
Less airway trauma
Minimal cervical spine motion12,39,40
Lower cardiovascular stimulation41---43
Versatility
Diagnostic and therapeutic functions
Airway instillation of drugs (i.e. local anesthetics in
spray as you go)
Positioning and conrmation of double-lumen tube or
bronchial blocker.
Change of ETT
Intubation through supraglottic devices
Transillumination
O2 insufation (not recommended except in
exceptional situations).
Ideal device for combining with other techniques
(retrograde, LMA, etc.)

Table 2 Conditions necessary to optimize beroptic intubation technique.


Experience and assistance
Knowledge of indications/contraindications of the
technique
Awake intubation
Proper preparation, information, monitoring
Sedation, topical anesthesia, anticholinergics,
vasoconstrictors
Suitable ancillary equipment
Reduction of the discordance in beroptic bronchoscope
and endotracheal tube diameter

cases of unpredicted DA. FOI is recognized by publications


and textbooks with statements like, mainstay of difcult
airway management in awake, sedated, and anesthetized
patients,6 unique role in several clinical scenarios,6
method of choice for securing the airway in patients with
airway trauma,19 gold standard technique in managing
difcult intubation,20 effective when no other technique
short of an invasive airway is likely to succeed,20 or the
most superior of all nonsurgical methods for airway control.21
The FB had not competent alternative until the beginning of the 21st century with the emergence of the video
laryngoscopy. Video laryngoscopes (VL) are fabulous devices
that offer an improved view and a higher intubation success rate compared with conventional direct laryngoscopy.22
Its unquestionable utility is reected in many cases,23,24
allowing its inclusion in different DA algorithms,17 airway management in critical care25 and pediatric airway
management.26 However there is no perfect device22 ; thus
(1) all VL share an important limitation: the inability to
correct the direction of TET unlike FOB. Thus, a good visualization does not guarantee intubation. They habitually

require a stylet as an adjuvant, although it is sometimes


insufcient; (2) they produce greater oropharyngeal trauma
since advancement of the ETT is not visible until it appears
on the monitor; (3) VL require a minimum interincisor distance of 15---20 mm to insert the blade; (4) there are multiple
models of VL; and (5) another important limitation is that
there is only solid evidence in subjects at higher risk of difculty during DL. In other scenarios as known difcult or
failed DL the evidence is weak or absent.27
With all of this, which technology is superior: FOB or VL?
Randomized clinical trials (RCT) are needed to answer this
question, but there are only 10 RCT,12,13,28---35 two of them
on mannequin model,34,35 a number insufcient to draw
conclusions. However, the VL was not superior in practically
any parameter, there is no signicant difference in time to
tracheal intubation and better glottic view (better POGO
scoring), and lower cervical mobilization was recorded with
FOB compared to VL. Anyway, besides being important to
know the superiority of one technique over another it is
interesting their synergy. Both techniques have disadvantages and no device is infallible in all circumstances, but the
combined use can overcome individual limitations increasing
the success rate.36 Thus, through the multimodal therapy,
the VL provides an unobstructed route to FB, placing it in the
vicinity of the glottis and allows visualization of the advance
of ETT on FB to the glottis, while the FB can overcome the
existing acute angle between the ETT and the glottis.36
Recently, Law et al.37 published an interesting retrospective review of awake tracheal intubation in a period
of 12 years. A FOB was used to facilitate awake intubations in 99.2% of the 1554 patients analyzed, attempted
awake intubation failed in 2% of the cases, most of them
could potentially be prevented improving the technique,
while an incidence of 15.7% of technical complications clinically trivial was recorded. Likewise, they analyzed the use
of alternatives methods after failure of the direct laryngoscopy in the same period. The use of VL reached the point
of inection in 2010. This reects the lack of evidence for
VL. Thus, the VL has an accumulated experience of 5 years
compared with more than 50 years of use of FOB. Currently
the VL can be considered the technique of choice in the
unexpected DA for its immediate availability,38 but it can
not replace awake intubation with FB for the patient with a
recognized DA because they are limited devices in the presence of pathological conditions or anatomical congurations
that are predictors of DA.38
The FB is the gold standard for the management of the
predicted DA in awake patient and its use as a rescue
technique with preserved ventilation should be done early,
to avoid a dramatic cannot intubate, cannot ventilate
scenario. Currently, FOB cannot be replaced by VL but highquality multicenter RCT are needed to determine the exact
role of both technologies in airway management. Anyway
the FOB will continue saving lives and brains for long time.

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