Review

A review of a journal article created by a Journal Watch contributor

Efficacy of a hybrid technique of simultaneous videolaryngoscopy with flexible bronchoscopy in children with difficult direct laryngoscopy in the Pediatric Difficult Intubation Registry

Anaesthesia

Submitted December 2023 by Dr David Rawson

Read by 125 Journal Watch subscribers

This study examined the effectiveness and safety of a hybrid technique – videolaryngoscope (VL) with flexible bronchoscope (FB) – in paediatric patients with difficult tracheal intubation.

Methods:
- A retrospective analysis of data from the International Paediatric Difficult Intubation Registry from 2017-2021
- The hybrid technique was compared to FB alone

Results:
After propensity score matching, groups were well balanced:
- Hybrid group: 140 patients for 182 intubation attempts

- FB group: 560 patients for 800 intubation attempts

The primary outcome was first-attempt successful intubation rate:
- There was NO significant difference between hybrid and FB groups
- This was the case whether used as a primary technique or as a rescue technique

Secondary outcomes:
- Eventual success rate - NO significant difference between the groups
- Complication rate - NO significant difference (and severe complications were very rare)
- Technical difficulty - higher in the Hybrid group (36%) than the FB group (28%), p = 0.04

The most common difficulty in the hybrid group was ‘directing the tracheal tube despite an adequate view’

The use of standard or hyperangulated laryngoscope blade made NO difference to first attempt or eventual success rates in the hybrid group

Crossover encounters
- A hybrid technique was able to rescue a failed FB technique in 21/24 cases
- An FB technique was able to rescue a failed hybrid technique in 2/7 cases

Limitations:
- Observational study, so no randomisation
- Groups matched for age, weight, ASA, sex. Possible other confounders exist.
- No consideration of the differences of experience of the intubating anaesthetist

Thoughts:
- While not demonstrated here as a ‘game-changer’, the Hybrid technique provides a safe and efficacious alternative to other ‘hi-tech’ advanced airway techniques. It is, I think, certainly worth considering as part of a paediatric difficult airway plan.
- Technical difficulties are significant. The pre-matched data shows that Hybrid success rates improve with increasing weight and age (whereas FB success rates no not). This might suggest that one of the big challenges is training to expertly manipulate 2 airway devices (by 2 operators and with 2 screens) in the confined physical space of an infant airway.
- It is used more commonly than FB as a rescue device, and does seem to have good results in that context.

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