Combined laryngo-bronchoscopy intubation approach in the normal airway scenario: a simulation study on anesthesiology residents

Simulators aid airway training and also familiarization with new devices and techniques. Direct laryngoscopy (DL) is the most used method for endotracheal intubation (ETI), followed by video-laryngoscopy (VLS). The combined use of laryngoscopy with fiberoptic bronchoscope (combined laryngo-bronchoscope intubation, CLBI) has been proposed but its performances in novices and the best timing for introduction during training remain not explored. We performed a randomized, crossover study evaluating the CLBI approach in simulated normal airway scenario. Ninety-six anesthesia residents performed ETI with four approaches: DL, Glidescope & REG;, McGrath & REG; and CLBI. Residents were allowed maximum 3 attempts (up to 60 seconds each). Main outcomes were success rate (SR) and time-to-intubation corrected for SR (cTTI). Subgroup analysis was performed separating residents according to their experience (junior, n = 60; senior, n = 36). At first attempt, DL had higher SR (97%) than CLBI (50%, p < 0.001), Glidescope & REG; (84%, p = 0.01) and McGrath & REG; (67%, p < 0.001). After 3 attempts, ETI failure was higher for CLBI (19%) than with Glidescope & REG; (2%, p < 0.001) or DL (1%, p < 0.001). CLBI showed longer cTTI (72(112) sec) than other devices (all p < 0.001: Glidescope & REG; 25(23) sec, McGrath & REG; 30(67) sec, DL 15(9) sec). The CLBI was the only approach performing better in senior as compared to junior residents (p = 0.03). In a normal airway simulation scenario, anesthesiology residents had lower SR and longer cTTI with CLBI technique as compared to DL and VLS. Our results suggest that CLBI could be introduced at senior stage of training, after DL and fiberoptic bronchoscope skills have been consolidated.