Combined Videolaryngoscopy and Flexible Bronchoscopy for Difficult Pediatric Intubation: A Review of Lin et al., Anaesthesia 2025
Background
Video-assisted fiberoptic intubation (VAFI) has emerged as an exciting frontier with the arrival of integrated airway management systems, such as the Glidescope CORE, which enable seamless transitions between video and fiberoptic tools on dual-screen monitors. Clinicians are only beginning to tap into the full potential of what these sophisticated devices can offer.
New evidence from the pediatric airway world now offers even more reason to master both videolaryngoscopy and fiberoptic intubation. In their recent retrospective observational study, Lin and colleagues highlight the advantages of an advanced hybrid approach — combining videolaryngoscopy (VL) with flexible bronchoscopy (FB) to tackle these challenging cases.
Drawing on data from over 550 challenging airway encounters at a major pediatric quaternary center, the team compared the first-attempt success rates and complication profiles of direct laryngoscopy, VL, FB, and the hybrid technique (simultaneous VL and FB). The results? The hybrid approach stood out.
🔑 Key Findings:
- First-attempt success was highest with the hybrid technique (74.5%) compared to VL (60.9%) or direct laryngoscopy (10%).
- When VL failed, adding FB as a rescue tool succeeded in over 70% of cases.
- Importantly, the hybrid technique was associated with a significantly lower complication rate (5.3%) compared to VL (14%) or direct laryngoscopy (21.6%).
Take Home
What makes this hybrid approach powerful is its synergy. VL offers enhanced external visualization, while FB provides internal precision and flexibility, acting as both a flexible stylet and a visual guide. This dual approach not only improves alignment and tube delivery but may also reduce airway trauma by minimizing blind maneuvers.
Perhaps most notably, the study underscores that using hybrid techniques early, not just as a rescue, could be a paradigm shift. While guidelines have increasingly endorsed VL as a first-line tool, Lin et al. make a compelling case for proactively incorporating flexible bronchoscopic assistance when difficulty is anticipated.
For educators and clinicians alike, the message is clear: mastering combined VL + FB techniques isn’t just a nice-to-have — it’s a crucial step in optimizing safety, success, and patient outcomes in some of the most vulnerable airway scenarios.
- Lin, H., Lyons, C., Ong, K.-B. and Lin, R. (2025), Combined videolaryngoscopy and flexible bronchoscopy for difficult tracheal intubation in children: a retrospective observational cohort study. Anaesthesia. https://doi.org/10.1111/anae.16624
