Declining fibreoptic intubation use in the videolaryngoscopy era

In their editorial accompanying the international survey by Cortese et al. [1], Hansel and Zdravkovic highlight that awake tracheal intubation is now performed infrequently, and that this may be related partly to the widespread introduction of videolaryngoscopy [2]. In a retrospective cohort study, we found that the introduction of videolaryngoscopy was associated with a marked replacement of flexible bronchoscopic tracheal intubation in difficult airway management [3]; use decreased by approximately 43%, both awake and under anaesthesia. The overall use of flexible bronchoscopic tracheal intubation decreased by 81% for unanticipated difficult intubation; 79% for patients with a history of difficult intubation; 66% for anticipated difficult intubation; and 26% for cervical pathologies. In contrast, the use of flexible bronchoscopic tracheal intubation remained unchanged in patients with reduced mouth opening. We further investigated the indications for choosing videolaryngoscopy or flexible bronchoscopy for anticipated and unanticipated difficult tracheal intubation in a prospective observational study conducted over 1 year [4]. Videolaryngoscopy was used in most patients. Flexible bronchoscopy was used mainly in patients with reduced mouth opening and upper airway or neck pathology, where its use was comparable to that of videolaryngoscopy. New technologies in medicine may lead to deskilling in techniques that were previously standard practice. Our findings support the concern of Hansel and Zdravkovic that awake tracheal intubation has become a high-acuity, low-occurrence event, and suggest that anaesthetists completing training today may have less experience with flexible bronchoscopy, including its use for awake tracheal intubation. Departments should therefore support structured training to promote the acquisition and maintenance of proficiency in awake tracheal intubation [5].