• Rainer Lenhardt, Mary Tyler Burkhart, Guy N Brock, Sunitha Kanchi-Kandadai, Rachana Sharma, and Ozan Akça.
• From the *Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, Louisville, Kentucky; †Outcomes Research Consortium, Cleveland, Ohio; and ‡School of Public Health and Information Sciences, University of Louisville, Louisville, Kentucky.
• Anesth. Analg.. 2014 Jun 1;118(6):1259-65.

BackgroundFailed intubation may result in both increased morbidity and mortality. The combination of a video laryngoscope and a flexible tracheoscope used as a flexible video stylet may improve the success rate of securing a difficult airway. We tested the hypothesis that this combination is a feasible way to facilitate intubation in patients with a predicted difficult airway in that it will shorten intubation times and reduce the number of intubation attempts.MethodsWe conducted a randomized, prospective trial in 140 patients with anticipated difficult airways undergoing elective or urgent surgery. After insertion of video laryngoscope, patients were randomly assigned to either having their tube placed with the use of a preformed stylet (control group) or with a flexible tracheoscope (intervention group). The primary outcome measures were time to successful intubation and number of intubation attempts.ResultsThe number of intubations requiring 2 or more intubation attempts was similar in the 2 groups (14% control vs 13% intervention, P = 1.0); the number of patients requiring 3 or more intubation attempts was not significantly different (8.6% control vs 1.4% intervention, P = 0.12). Distribution for time to intubation also did not differ between the control (median of 66 seconds, interquartile range 47-89) and the intervention group (median of 71 seconds, interquartile range 52-100; P = 0.35). In the control group, 4 patients, all with cervical spine pathology, had the trachea intubated successfully with the video laryngoscope plus flexible tracheoscope after 3 failed attempts with video laryngoscope and rigid stylet. For these 4 patients, time from the decision to change the intubation method to successful intubation with a flexible tracheoscope was 36 ± 14 seconds. Overall success probability for cervical spine patients was 100% (20/20) in the intervention group and 80% (16/20) in the control group, with an exact 95% confidence interval for the difference of 1.4% to 44%, P = 0.04.ConclusionsFlexible tracheoscope-assisted video laryngoscopic intubation is a feasible alternative to video laryngoscope only intubation in patients with predicted difficult airways. A flexible tracheoscope used in combination with video laryngoscope may also further increase the success rate of intubation in select patients with a proven difficult airway, particularly when in-line stabilization is required.

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