Failure Rates for Endotracheal Tube Placement Using Videolaryngoscopy in Patients with a Difficult Airway

Airway management has undergone dramatic transformation since the development of videolaryngoscopy (VL). VL improves glottic views when compared to direct laryngoscopy (DL). The image obtained is from a camera at the tip of the curved blade, and the view is not direct line of sight. Placement of the endotracheal tube (ETT) may therefore require the ETT to be manipulated in multiple planes to match the curvature of the VL blade. This placement of the ETT "around the corner" may be difficult without additional airway aids. The aim of this retrospective observational study was to determine whether endotracheal placement during VL in patients with a difficult airway required the use of an additional airway aid (bougie or fiberoptic scope). Difficult airway was defined as a Cormack and Lehane (C&L) grade 3 or 4 view obtained using DL prior to VL use. Data from 165 patients was included in the study. Simple ETT placement without an additional airway device was achieved in only 20.6% of cases (n = 34). The remaining 131 patients required a bougie or fiberscope to assist intubation. ETT placement was not possible with the bougie in 33 patients. These 33 patients were successfully intubated using a fiberscope-assisted VL (FAV) technique. VL improved C&L grade 3 views by at least one grade in 99.1% of cases, and grade 4 view to a grade 1 or 2 in 96.3% of cases. VL improves glottic view in patients with a difficult airway; but in nearly 80% of patients, a bougie or fiberscope is required to properly place the ETT. Practitioners should be aware that improved glottic views with VL may not translate into simple ETT placement, and additional airway aids need to be readily available.