Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry

Authors

Mary Lyn Stein, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Julia Heunis Nagle, Department of Pediatrics, Boston Children's Hospital, Boston, MA, USA.
T Wesley Templeton, Department of Anesthesiology, Wake Forest School of Medicine, Winston Salem, NC, USA.
Steven J. Staffa, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Stephen G. Flynn, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Martina Bordini, Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.
Sydney Nykiel-Bailey, Department of Anesthesiology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
Annery G. Garcia-Marcinkiewicz, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Febina Padiyath, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Maria Matuszczak, Department of Anesthesiology, Critical Care, and Pain Medicine, McGovern Medical School at UT Health, Texas Medical Center, Houston, TX, USA.
Angela C. Lee, Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, D.C., USA.
James M. Peyton, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Raymond S. Park, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
Britta S. von Ungern-Sternberg, Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Institute for Paediatric Perioperative Excellence, The University of Western Australia.
Patrick N. Olomu, Department of Anesthesia, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA.
Agnes I. Hunyady, Department of Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
Clyde Matava, Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.
John E. Fiadjoe, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Pete G. Kovatsis, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.

Document Type

Journal Article

Publication Date

3-20-2025

Journal

Anaesthesia

DOI

10.1111/anae.16576

Keywords

difficult airway; flexible bronchoscopy; paediatric anaesthesia; tracheal intubation; videolaryngoscopy

Abstract

INTRODUCTION: Flexible bronchoscopy is the gold standard for difficult airway management. Clinicians are using videolaryngoscopy increasingly because it is perceived to be easier to use with high success rates. We conducted this study to compare the success rates of the two techniques when used after failed direct laryngoscopy in children with difficult tracheal intubations. METHODS: We identified cases where initial attempts at direct laryngoscopy failed in the multicentre Pediatric Difficult Intubation Registry from August 2012-September 2023. After propensity score matching, we compared success rates and complications when videolaryngoscopy and flexible bronchoscopy were used as rescue techniques in the matched cohort and in matched patients weighing < 5 kg. RESULTS: Clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy when direct laryngoscopy failed (64.7%, 1426/2281 vs. 7.3%, 156/2281, p < 0.001). Propensity score matched cohorts did not differ with respect to first-attempt success, eventual success and complications. For the subgroup of infants < 5 kg, clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy to rescue failed direct laryngoscopy (54.3%, 295/543 vs. 8.9%, 44/543, p < 0.001). First-attempt success was 43% (62/145) with videolaryngoscopy and 62% (18/29) with flexible bronchoscopy (odds ratio 2.19, 95%CI 0.96-4.98, p = 0.061). Eventual success was 71% (103/145) with videolaryngoscopy and 90% (26/29) with flexible bronchoscopy (odds ratio 3.53, 95%CI 1.03-12.2, p = 0.046). Complications did not differ between the techniques. DISCUSSION: Videolaryngoscopy was chosen more frequently than flexible bronchoscopy as a rescue technique in a cohort of children with difficult direct laryngoscopy, with similar success and complication rates. For small infants, flexible bronchoscopy had a higher eventual success rate, underscoring the importance of maintaining proficiency with flexible bronchoscopy.

APA Citation

Stein, Mary Lyn; Nagle, Julia Heunis; Templeton, T Wesley; Staffa, Steven J.; Flynn, Stephen G.; Bordini, Martina; Nykiel-Bailey, Sydney; Garcia-Marcinkiewicz, Annery G.; Padiyath, Febina; Matuszczak, Maria; Lee, Angela C.; Peyton, James M.; Park, Raymond S.; von Ungern-Sternberg, Britta S.; Olomu, Patrick N.; Hunyady, Agnes I.; Matava, Clyde; Fiadjoe, John E.; and Kovatsis, Pete G., "Comparing videolaryngoscopy and flexible bronchoscopy to rescue failed direct laryngoscopy in children: a propensity score matched analysis of the Pediatric Difficult Intubation Registry" (2025). GW Authored Works. Paper 6781.
https://hsrc.himmelfarb.gwu.edu/gwhpubs/6781

Department

Anesthesiology and Critical Care Medicine