Related Experiment Video
Updated: May 23, 2025
Guidelines for Elective Pediatric Fiberoptic Intubation
Published on: January 17, 2011
Combined videolaryngoscopy and flexible bronchoscopy for difficult tracheal intubation in children: a retrospective
Helen Lin1, Craig Lyons2, Kar-Binh Ong2
1Critical Care Unit, Anaesthetics Department, The Royal Marsden NHS Foundation Trust, London, UK.
Insights
The hybrid technique for pediatric tracheal intubation offers the highest first-attempt success rate in difficult airways. This method also shows a lower incidence of complications compared to videolaryngoscopy or direct laryngoscopy.
Area of Science:
- Anesthesiology
- Pediatric Critical Care
- Airway Management
Background:
- Difficult pediatric airways pose significant risks for intubation-related complications.
- Alternative intubation techniques include videolaryngoscopy, flexible bronchoscopy, and a hybrid approach.
Purpose of the Study:
- To compare the first-attempt success rates of different tracheal intubation techniques in children.
- To assess the incidence of complications associated with difficult pediatric intubations using various methods.
Main Methods:
- Retrospective analysis of electronic health records from a quaternary pediatric hospital.
- Defined difficult intubation by Pediatric Difficult Intubation Registry criteria or ≥3 attempts.
- Primary outcomes: first-attempt success rate and complication incidence per technique.
Main Results:
- The hybrid technique demonstrated the highest first-attempt success rate (74.5%) compared to videolaryngoscopy (60.9%) and direct laryngoscopy (10.0%).
- The hybrid technique successfully rescued 70.4% of cases where videolaryngoscopy alone failed.
- Complication rates were lower with the hybrid technique (5.3%) versus videolaryngoscopy (14.0%) and direct laryngoscopy (21.6%).
- Patients <10 kg had a significantly higher complication rate (24.5%).
Conclusions:
- The hybrid technique is associated with superior first-attempt success in difficult pediatric tracheal intubations.
- This approach also demonstrates a reduced incidence of complications.
- The hybrid technique should be considered a primary option for anticipated difficult intubations and after failed attempts with other methods.
Introduction:
Children with difficult airways are at high risk of complications. Alternative techniques to direct laryngoscopy for tracheal intubation include videolaryngoscopy, flexible bronchoscopy and the hybrid technique of simultaneous videolaryngoscopy and flexible bronchoscopy. This analysis aimed to compare the first-attempt success of each technique and assess the complications associated with difficult paediatric intubations in a quaternary paediatric institution.
Methods:
The electronic health records of a single quaternary paediatric hospital were searched to identify anaesthesia encounters involving difficult paediatric intubation. This was defined either by the Pediatric Difficult Intubation Registry criteria or as tracheal intubation requiring ≥ 3 attempts. Primary outcomes were the first-attempt success rate and incidence of complications with each tracheal intubation technique.
Results:
From April 2019 to January 2024, 559 encounters involving difficult tracheal intubation were identified. First-attempt success was highest for the hybrid technique (70/94, 74.5%) compared with videolaryngoscopy (143/235, 60.9%, p = 0.020) or direct laryngoscopy (19/190, 10.0%, p < 0.001). The hybrid technique was used to rescue 19/27 (70.4%) encounters where videolaryngoscopy alone was unsuccessful and was successful in all these encounters. Eighty-six (15.4%) encounters had at least one complication. The complication rate was significantly higher for patients weighing < 10 kg (45/184, 24.5%) compared with those weighing ≥ 10 kg (41/375, 10.9%, p < 0.001). The hybrid technique was associated with a lower incidence of complications (5/94, 5.3%) compared with videolaryngoscopy (33/235, 14.0%, p = 0.025) or direct laryngoscopy (41/190, 21.6%, p < 0.001).
Discussion:
In children with difficult tracheal intubation, the hybrid technique was associated with a higher first-attempt success rate compared with videolaryngoscopy alone or direct laryngoscopy. Consideration should be given to the hybrid technique as a first-line approach when difficult tracheal intubation is anticipated and when there is a failed attempt with either direct laryngoscopy or videolaryngoscopy.
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