Comparison of tracheal intubation using videolaryngoscopy versus videolaryngoscope-assisted flexible tracheoscopy in patients with simulated manual in-line stabilisation – A randomised controlled trial

Background and Aims: Airway management in cervical spine injury is challenging, and combining videolaryngoscopy with a flexible tracheoscope could enhance glottic visualisation, addressing the limitations when used alone. This prospective, open-label, randomised trial compared videolaryngoscopy-assisted flexible tracheoscopy (VLF) with videolaryngoscopy using a rigid stylet (VLS) for orotracheal intubation under simulated manual in-line stabilisation (MILS). Methods: A total of 158 American Society of Anesthesiologists physical status class I–III patients, aged 18–60 years, scheduled for elective surgery under general anaesthesia were enroled; 157 were analysed (VLF, n = 79; VLS, n = 78). Patients with an anticipated difficult airway, body mass index >30 kg/m 2 , or cervical spine pathology or requiring rapid sequence induction were excluded. After induction and application of MILS, an experienced anaesthesiologist performed orotracheal intubation. The primary outcome was time to successful intubation. Secondary outcomes were first-attempt success and complications (desaturation, mucosal trauma, post-operative sore throat). Results: The median (interquartile range) intubation time was significantly shorter with VLF [66 (57–78) s] compared to VLS [80 (70–95) s], with a median difference of 14 s (95% confidence interval: 8,18; P < 0.001). First-attempt success was 100% in Group VLF and 86% in Group VLS ( P < 0.001). Three patients in the VLS group required removal of MILS due to intubation failure, whereas all VLF intubations were successful under stabilisation. The incidences of complications did not differ significantly between the groups. Conclusion: VLF provided faster and more reliable intubation than VLS during MILS, without increase in complications. This technique may be a valuable option for airway management when cervical spine movement must be minimised.