Videolaryngoscopy versus fiberoptic bronchoscope for awake intubation – a systematic review and meta-analysis of randomized controlled trials

Figures & data

Figure 1 Searching process of identified records.

Abbreviation: RCTs, randomized clinical trials.

Table 1 Characteristics of included studies

Studies	Methods	N	Surgical type	Comparisons	Inclusion criteria	Exclusion criteria	Anesthesia method	No of experienced operators	Intubation protocol
Abdellatif and Ali (2014)^Citation16	RCT	64	Laparoscopic bariatric surgery	GVL and FOB	BMI >40; difficult airway	Age 18–60; ASA >IV; severe mental disorder; mouth opening limitation; poor dental status	Topical; remifentanil TCI	Two experienced operators	Change after three attempts
Kramer et al (2015)^Citation21	RCT	100	Oral-facial surgery	C-MAC and FOB	Nasal TI for a surgery or difficult intubation; age >18; mouth opening >1.3 cm	Dental abscesses or ASA >IV	Topical anesthesia, midazolam, remifentanil	Nine experienced attending anesthetists	Change after all maneuvers used
Mendonca et al (2016)^Citation17	RCT	40	Elective surgery	AWS and FOB	A high Mallampati score, limited neck extension, limited jaw protrusion or a requirement to maintain the cervical spine in the neutral position during intubation, and scheduled to undergo elective surgery under general anesthesia	Nasal TI; age <18; pregnant; mouth opening <2.5 cm	Topical anesthesia; remifentanil TCI; midazolam	One experienced operator	Not clear
Rosenstock et al (2012)^Citation23	RCT	93	Gynecologic, abdominal, urologic, ear, nose, and throat surgery	McGrath Series 5 and FOB	Adult, ASA I–III; anticipated difficult laryngoscopy or intubation	Mouth opening <15; poor dental status; nasal intubation; contradiction for transtracheal injection	Continuous remifentanil, topical analgesia (transtracheal injection)	Six experienced operators	Change after three attempts
Mahran and Hassan (2017)^Citation22	RCT	54	Oropharyngeal cancer	GVL and FOB	Age 20–60 years, ASA I–II, Mallampati 2–3, need nasal intubation	Restricted mouth opening; bleeding tendency; patient refusal	Topical analgesia, remifentanil	Two experienced operators	Not mentioned (but all successful after three attempts)
Wahba et al (2012)^Citation24	RCT	50	Selective cervical spine fixation	GVL and FOB	ASA I–II patients, ages 26–44	BMI >35 kg/m^2; obstructive airway disease; cardiovascular disease; apparent airway difficulty or upon patient refusal	Topical analgesia, remifentanil	All experienced	Change after three attempts

Abbreviations: ASA, American Statistical Association; GVL, glidescope videolaryngoscope; AWS, Airway Scope; BMI, body mass index; FOB, fiberoptic bronchoscope; RCT, randomized controlled trial; TCI, targeted controlled infusio.

Figure 2 Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.

Figure 3 VL vs DL for overall success rate.

Abbreviations: FOB, fiberoptic bronchoscope; M–H, Mantel-Haenszel method; VL, videolaryngoscopy.

Table 2 Results of meta-analysis for subgroup analysis and secondary outcomes between VL and FOB

Outcomes	Studies, N	Participants, N	Heterogeneity	Heterogeneity statistical method	Effect estimate, (95% CI), (P-value)
Overall success rate (nasal)	2	208	P=1.00; I^2=0%	Risk ratio (M–H, fixed, 95% CI)	1.00 (0.97–1.03) (1.00)
Overall success rate (oral)	4	238	P=0.80; I^2=0%	Risk ratio (M–H, fixed, 95% CI)	1.00 (0.96–1.04) (0.98)
First-attempt success rate	4	252	P=0.45; I^2=0%	Risk ratio (M–H, fixed, 95% CI)	1.03 (0.90–1.17) (0.71)
Rate of low oxygen saturation	5	333	P=0.90; I^2=0%	Risk ratio (M–H, fixed, 95% CI)	0.47 [0.21–1.06) (0.07)
Rate of sore throat	3	167	P=0.59; I^2=0%	Risk ratio (M–H, fixed, 95% CI)	1.02 (0.59–1.77) (0.94)

Abbreviations: FOB, fiberoptic bronchoscope; VL, videolaryngoscopy.

AbdellatifAAAliMAGlideScope videolaryngoscope versus flexible fiberoptic bronchoscope for awake intubation of morbidly obese patient with predicted difficult intubationMiddle East J Anaesthesiol201422438539225007692

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KramerAMüllerDPförtnerRMohrCGroebenHFibreoptic vs videolaryngoscopic (C-MAC(®) D-BLADE) nasal awake intubation under local anaesthesiaAnaesthesia201570440040625764403

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MendoncaCMesbahAVelayudhanADanhaRA randomised clinical trial comparing the flexible fibrescope and the Pentax Airway Scope (AWS)(®) for awake oral tracheal intubationAnaesthesia201671890891427228959

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RosenstockCVThøgersenBAfshariAChristensenALEriksenCGätkeMRAwake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trialAnesthesiology201211661210121622487805

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MahranEAHassanMEComparative randomised study of GlideScope® video laryngoscope versus flexible fibre-optic bronchoscope for awake nasal intubation of oropharyngeal cancer patients with anticipated difficult intubationIndian J Anaesth2016601293693828003696

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WahbaSSTammamTFSaeedAMComparative study of awake endotracheal intubation with Glidescope video laryngoscope versus flexible fiber optic bronchoscope in patients with traumatic cervical spine injuryEgypt J Anaesth2012284257260

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