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Original Research

Open Access

Combined laryngo-bronchoscopy intubation approach in the normal airway scenario: a simulation study on anesthesiology residents

  • Luigi La Via1,*,
  • Simone Messina2
  • Federica Merola3
  • Francesco Tornitore2
  • Giulia Sanfilippo2
  • Cristina Santonocito1
  • Alberto Noto4
  • Federico Longhini2
  • Marinella Astuto1,†
  • Filippo Sanfilippo1,*,†,

1Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, site “Policlinico G. Rodolico”, 95123 Catania, Italy

2School of Anesthesia and Intensive Care, University “Magna Graecia”, 88100 Catanzaro, Italy

3School of Anesthesia and Intensive Care, University of Catania, 95100 Catania, Italy

4Department of Anesthesia and Intensive Care, University of Messina, 98100 Messina, Italy

DOI: 10.22514/sv.2023.053 Vol.19,Issue 4,July 2023 pp.91-98

Submitted: 21 July 2022 Accepted: 30 August 2022

Published: 08 July 2023

*Corresponding Author(s): Luigi La Via E-mail:
*Corresponding Author(s): Filippo Sanfilippo E-mail:

† These authors contributed equally.


Simulators aid airway training and also familiarization with new devices and techniques. Direct laryngoscopy (DL) is the most used method for endotracheal intubation (ETI), followed by video-laryngoscopy (VLS). The combined use of laryngoscopy with fiberoptic bronchoscope (combined laryngo-bronchoscope intubation, CLBI) has been proposed but its performances in novices and the best timing for introduction during training remain not explored. We performed a randomized, crossover study evaluating the CLBI approach in simulated normal airway scenario. Ninety-six anesthesia residents performed ETI with four approaches: DL, Glidescope®, McGrath® and CLBI. Residents were allowed maximum 3 attempts (up to 60 seconds each). Main outcomes were success rate (SR) and time-to-intubation corrected for SR (cTTI). Subgroup analysis was performed separating residents according to their experience (junior, n = 60; senior, n = 36). At first attempt, DL had higher SR (97%) than CLBI (50%, p < 0.001), Glidescope® (84%, p = 0.01) and McGrath® (67%, p < 0.001). After 3 attempts, ETI failure was higher for CLBI (19%) than with Glidescope® (2%, p < 0.001) or DL (1%, p < 0.001). CLBI showed longer cTTI (72(112) sec) than other devices (all p < 0.001: Glidescope® 25(23) sec, McGrath® 30(67) sec, DL 15(9) sec). The CLBI was the only approach performing better in senior as compared to junior residents (p = 0.03). In a normal airway simulation scenario, anesthesiology residents had lower SR and longer cTTI with CLBI technique as compared to DL and VLS. Our results suggest that CLBI could be introduced at senior stage of training, after DL and fiberoptic bronchoscope skills have been consolidated.


Direct laryngoscopy; Endotracheal intubation; Fiberoptic bronchoscope; Manikin; Simulation; Video-laryngoscopy

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Luigi La Via,Simone Messina,Federica Merola,Francesco Tornitore,Giulia Sanfilippo,Cristina Santonocito,Alberto Noto,Federico Longhini,Marinella Astuto,Filippo Sanfilippo. Combined laryngo-bronchoscopy intubation approach in the normal airway scenario: a simulation study on anesthesiology residents. Signa Vitae. 2023. 19(4);91-98.


[1] Stevenson AGM, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal intubation in the emergency department: the Scottish district hospital perspective. Emergency Medicine Journal. 2007; 24: 394–397.

[2] Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Critical Care Medicine. 2014; 42: 169–178.

[3] Sanfilippo F, Tigano S, La Rosa V, Morgana A, Murabito P, Oliveri F, et al. Tracheal intubation while wearing personal protective equipment in simulation studies: a systematic review and meta-analysis with trial-sequential analysis. Brazilian Journal of Anesthesiology. 2022; 72: 291–301.

[4] Mulcaster JT, Mills J, Hung OR, MacQuarrie K, Law JA, Pytka S, et al. Laryngoscopic intubation: learning and performance. Anesthesiology. 2003; 98: 23–27.

[5] Wamg HE, Reitz SR, Hostler D, Yealy DM. Defining the learning curve for paramedic student endotracheal intubation. Prehospital Emergency Care. 2005; 9: 156–162.

[6] Malik MA, O’Donoghue C, Carney J, Maharaj CH, Harte BH, Laffey JG. Comparison of the Glidescope®, the Pentax AWS®, and the Truview EVO2® with the Macintosh laryngoscope in experienced anaesthetists: a manikin study. British Journal of Anaesthesia. 2009; 102: 128–134.

[7] Kim JK, Kim JA, Kim CS, Ahn HJ, Yang MK, Choi SJ. Comparison of tracheal intubation with the airway scope or Clarus video system in patients with cervical collars. Anaesthesia. 2011; 66: 694–698.

[8] Shippey B, Ray D, McKeown D. Use of the McGrath® videolaryngo-scope in the management of difficult and failed tracheal intubation. British Journal of Anaesthesia. 2008; 100: 116–119.

[9] Maharaj CH, Costello JF, Higgins BD, Harte BH, Laffey JG. Learning and performance of tracheal intubation by novice personnel: a comparison of the Airtraq and Macintosh laryngoscope. Anaesthesia. 2006; 61: 671–677.

[10] Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber J. Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study. European Journal of Anaesthesiology. 2009; 26: 554–558.

[11] Maharaj CH, McDonnell JG, Harte BH, Laffey JG. A comparison of direct and indirect laryngoscopes and the ILMA in novice users: a manikin study. Anaesthesia. 2007; 62: 1161–1166.

[12] Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber JL. Comparison of the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes in simulated difficult airways*. Anaesthesia. 2008; 63: 1358–1364.

[13] Park J, An S, Park S, Nahm FS, Han S, Kim J. Comparison of a new video intubation stylet and McGrath® MAC video laryngoscope for intubation in an airway manikin with normal airway and cervical spine immobilization scenarios by novice personnel: a randomized crossover study. BioMed Research International. 2021; 2021: 1–7.

[14] Sanfilippo F, Messina S, Merola F, Tigano S, Morgana A, Dimagli A, et al. Endotracheal intubation during chest compressions in the pediatric simulation setting: a systematic review and meta-analysis. Signa Vitae. 2022; 18: 94–102.

[15] Oh JY, Lee JH, Kim YY, Baek SM, Jung DW, Park JH. A comparative study of glottis visualization according to the method of lifting the epiglottis in video laryngoscopy: indirect and direct lifting methods. Anesthesia and Pain Medicine. 2021; 16: 196–200.

[16] Sanfilippo F, Chiaramonte G, Sgalambro F. Video laryngoscopes and best rescue strategy for unexpected difficult airways: do not forget a combined approach with flexible bronchoscopy! Anesthesiology. 2017; 126: 1203.

[17] Sgalambro F, Sanfilippo F, Santonocito C, Caltavuturo C, Grillo C. Virtual laryngoscopy and combined laryngoscopic—bronchoscopic approach for safe management of obstructive upper airways lesions. British Journal of Anaesthesia. 2014; 113: 304–306.

[18] Nedrud SM, Baasch DG, Cabral JD, McEwen DS, Dasika J. Combined video laryngoscope and fiberoptic nasal intubation. Cureus. 2021; 13: e19482.

[19] Kim SM, Kim HJ. Successful advancement of endotracheal tube with combined fiberoptic bronchoscopy and videolaryngoscopy in a patient with a huge goiter. SAGE Open Medical Case Reports. 2020; 8: 2050313X20923232.

[20] Yukihiro Imajo, Komasawa N, Fujiwara S, Tsuji E, Minami T. Efficacy of a Bronchofiberscope in combination with the GlideScopee in a difficult airway patient. Masui. The Japanese Journal of Anesthesiology. 2016; 65: 1013–1015. (In Japanese)

[21] Sowers N, Kovacs G. Use of a flexible intubating scope in combination with a channeled video laryngoscope for managing a difficult airway in the emergency department. The Journal of Emergency Medicine. 2016; 50: 315–319.

[22] Murabito P, Astuto M, Sanfilippo F, La Via L, Vasile F, Basile F, et al. Proactive management of intraoperative hypotension reduces biomarkers of organ injury and oxidative stress during elective non-cardiac surgery: a pilot randomized controlled trial. Journal of Clinical Medicine. 2022; 11: 392.

[23] Sanfilippo F, Sgalambro F, Chiaramonte G, Santonocito C, Burgio G, Arcadipane A. Use of a combined laryngo-bronchoscopy approach in difficult airways management: a pilot simulation study. Turkish Journal of Anaesthesiology and Reanimation. 2019; 47: 464–470.

[24] Nishikawa K, Hukuoka E, Kawagishi T, Shimodate Y, Yamakage M. Efficacy of the Airtraq® laryngoscope with a fiberoptic bronchoscope compared with that of Airtraq® alone for tracheal intubation: a manikin study. Journal of Anesthesia. 2011; 25: 93–97.

[25] Krage R, van Rijn C, van Groeningen D, Loer SA, Schwarte LA, Schober P. Cormack-Lehane classification revisited. British Journal of Anaesthesia. 2010; 105: 220–227.

[26] Levitan RM, Ochroch EA, Rush S, Shofer FS, Hollander JE. Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale. Academic Emergency Medicine. 1998; 5: 919–923.

[27] Sanfilippo F, Sgalambro F, Astuto M. Management of difficult airways: which is the safest approach after reviewing virtual laryngo-tracheo-bronchoscopy imaging? Anesthesiology. 2015; 122: 469.

[28] Gomez-Rios MA, Nieto Serradilla L. Combined use of an Airtraq® optical laryngoscope, Airtraq video camera, Airtraq wireless monitor, and a fibreoptic bronchoscope after failed tracheal intubation. Canadian Journal of Anaesthesia. 2011; 58: 411–412.

[29] Greib N, Stojeba N, Dow WA, Henderson J, Diemunsch PA. A combined rigid videolaryngoscopy-flexible fibres copy intubation technique under-gener al anesthesia. Canadian Journal of Anesthesia. 2007; 54: 492–493.

[30] Liao X, Xue FS, Cheng Y, Li RP. Rescue intubation by combined use of video laryngoscopy and Bonfils fiberscope in patients with difficult airway. Saudi Medical Journal. 2013; 34: 970–971.

[31] Sharma D, Kim LJ, Ghodke B. Successful airway management with combined use of Glidescope® videolaryngoscope and fiberoptic bron-choscope in a patient with cowden syndrome. Anesthesiology. 2010; 113: 253–255.

[32] Hung WT, Yang MW, Lin CY. Evaluation of learning effectiveness in endotracheal intubation by the use of a laryngoscope in combination with a flexible fiberoptic bronchoscope. Acta Anaesthesiologica Sinica. 2001; 39: 129–133.

[33] Ruetzler K, Imach S, Weiss M, Haas T, Schmidt AR. Comparison of five video laryngoscopes and conventional direct laryngoscopy: Investigations on simple and simulated difficult airways on the intubation trainer. Die Anaesthesiologie. 2015; 64: 513–519.

[34] Eismann H, Sieg L, Etti N, Friedrich L, Schröter C, Mommsen P, et al. Improved success rates using videolaryngoscopy in unexperienced users: a randomized crossover study in airway manikins. European Journal of Medical Research. 2017; 22: 27.

[35] Piepho T, Weinert K, Heid FM, Werner C, Noppens RR. Comparison of the McGrath® series 5 and GlideScope® ranger with the macintosh laryn-goscope by paramedics. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2011; 19: 4.

[36] Yi IK, Kwak HJ, Lee KC, Lee JH, Min SK, Kim JY. Comparison of McGrath, Pentax, and Macintosh laryngoscope in normal and cervical immobilized manikin by novices: a randomized crossover trial. European Journal of Medical Research. 2020; 25: 35.

[37] Rendeki S, Keresztes D, Woth G, Mérei Á, Rozanovic M, Rendeki M, et al. Comparison of VividTrac®, Airtraq®, King Vision®, macintosh laryngoscope and a custom-made Videolaryngoscope for difficult and normal airways in mannequins by novices. BMC Anesthesiology. 2017; 17: 68.

[38] Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Critical Care Medicine. 2014; 42: 169–178.

[39] Doleman B, Blackwell J, Karangizi A, Butt W, Bhalla A, Lund JN, et al. Anaesthetists stress is induced by patient ASA grade and may impair non-technical skills during intubation. Acta Anaesthesiologica Scandinavica. 2016; 60: 910–916.

[40] Sanfilippo F, Martucci G, La Via L, Cuttone G, Dimarco G, Pulizzi C, et al. Hemoperfusion and blood purification strategies in patients with COVID-19: a systematic review. Artificial Organs. 2021; 45: 1466–1476.

[41] Schebesta K, Hüpfl M, Ringl H, Machata A, Chiari A, Kimberger O. A comparison of paediatric airway anatomy with the SimBaby high-fidelity patient simulator. Resuscitation. 2011; 82: 468–472.

[42] Schebesta K, Hüpfl M, Rössler B, Ringl H, Müller MP, Kimberger O. Degrees of reality: airway anatomy of high-fidelity human patient simulators and airway trainers. Anesthesiology. 2012; 116: 1204–1209.

[43] Blackburn MB, Wang SC, Ross BE, Holcombe SA, Kempski KM, Blackburn AN, et al. Anatomic accuracy of airway training manikins compared with humans. Anaesthesia. 2021; 76: 366–372.

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