Are Combined Techniques Using Video Laryngoscopes and Dynamic Stylets Superior to Fiberoptic Techniques for Anticipated Difficult Intubations? A Retrospective Case Control Study

Difficult intubations can require advanced intubation techniques. Studies point to potential advantages of combined techniques using video laryngoscopes (VL) and dynamic stylets for anticipated difficult intubations. This study is designed to compare combined techniques to awake and asleep fiberoptic (FOB) techniques. Methods: : 138,387 consecutive anaesthesia cases were reviewed for use of: FOB awake, FOB asleep, or combined technique (VL for visualization and either a FOB or a novel TCI TM articulating introducer ((TCI TM ; Through The Cords, LLC; Salt Lake City, UT)) as dynamic stylets as a primary approach for anticipated difficult intubations. Primary end points measured: first attempt success rate, failure to intubate with the primary technique, “in-room to intubation’ time, reported traumatic intubation rate, and reported ease of intubation. Results: : Significant differences were found between techniques. First pass success rate was highest in combined techniques (either VL + FOB or VL + TCI TM ) (88.7%) followed by FOB awake (74.2%, P<0.001) and FOB asleep (80.7%, P=0.06). “Failure to intubate with the primary technique” was lowest in combined techniques (1.8%) followed by FOB asleep (4.6%, P=0.11) and FOB awake (9.2%, P=0.002). “In room to intubated” time was fastest in combined techniques (13.0 minutes) followed by FOB asleep (15.1 minutes, P=0.002) and FOB awake (21.2 minutes, P<0.001). Combined techniques were rated as ‘easy’ more often (72%) followed by FOB asleep (62.9%, P=0.12) and FOB awake (38.2%, P<0.001). Combined techniques were rated as “atraumatic” more often (91.1%) followed by FOB asleep (89.4%, P=0.91) and FOB awake (75.8%, P<0.001). In subgroup analysis of combined techniques, VL + TCI TM had the highest first attempt success rate (90.2%), lowest failure rate (1%, P=0.56), and shortest “in room to intubated time” (12.1 minutes, P=0.12). It was also rated as "easy” (83.3%, P<0.001), and “atraumatic“ (96.1%, P=0.009) more often than VL + FOB, FOB awake or FOB asleep. Conclusions: : Combined techniques outperformed FOB techniques in terms of effectiveness, speed, ease of use, and patient injury in patients with risk factors for difficult intubation. As a sub-group of combined technique, VL + TCI TM outperformed all other techniques. Combined techniques should be considered when managing difficult intubations.