Eur J Anaesthesiol 2020; 37:443–450

ORIGINAL ARTICLE

Difficult airway management practice changes after

introduction of the GlideScope videolaryngoscope
A retrospective cohort study
Alexander Avidan, Yoel Shapira, Avital Cohen, Charles Weissman and Phillip D. Levin

BACKGROUND Introduction of the GlideScope videolaryn- (1.0%), P < 0.0001]. The GlideScope replaced flexible
goscope caused a change in use of other devices for difficult fibreoptic bronchoscopy in most cases with expected and
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airway management. unexpected difficult intubation. In patients with limited mouth

opening, flexible fibreoptic bronchoscopy was still mostly the
OBJECTIVE The influence of the GlideScope videolaryngo-
first choice after the introduction of the GlideScope. There
scope on changes in the indications for and the frequency of
was a 70% reduction in the use of other difficult intubation
use of flexible fibreoptic-assisted intubation and other diffi-
techniques after the introduction of the GlideScope [before
cult airway management techniques.
84/8306 (1.0%); after 22/8517 (0.3%), P < 0.0001)].
DESIGN Retrospective cohort study.
CONCLUSION The GlideScope videolaryngoscope
SETTING Tertiary care referral centre. replaced flexible fibreoptic bronchoscopy for most patients
with expected and unexpected difficult intubation. In the case
METHODS Two periods of equal length (647 days each)
of limited mouth opening, flexible fibreoptic bronchoscopy
before and after introducing the GlideScope were com-
was still the first choice after the introduction of the Glide-
pared. Information about patients who were intubated using
Scope. The reduced use of flexible fibreoptic bronchoscopy
nondirect laryngoscopic techniques were analysed. Data
raises concerns that residents may not be adequately trained
were retrieved from the anaesthesia and hospital information
in this essential airway management technique. GlideScope
management systems.
use was disproportionately greater than the reduction in the
RESULTS Difficult airway management techniques were use of flexible fibreoptic bronchoscopy and other difficult
used in 235/8306 (2.8%) patients before and in 480/ intubation techniques. This may be attributed to resident
8517 (5.6%) (P < 0.0001) patients after the introduction teaching and use in patients with low-to-moderate suspicion
of the GlideScope. There was an overall 44.4% reduction in of difficult intubation.
use of flexible fibreoptic bronchoscopy after GlideScope Published online 19 March 2020
introduction [before 149/8306 (1.8%); after 85/8517

Introduction
Videolaryngoscopy is increasingly used for difficult air- operative setting.8 Until the introduction of videolar-
way management in anaesthesia,1 – 3 intensive care units4 yngoscopy, intubation using flexible fibreoptic bron-
and emergency departments.5 Recently, videolaryngo- choscopy was regarded as the gold standard of
scopy has been incorporated into various difficult airway difficult airway management in anaesthesia.9 – 11 Studies
management algorithms,6,7 being recommended as one have shown that videolaryngoscopy can replace flexible
of the initial steps in the management of difficult air- fibreoptic bronchoscopy for difficult airway manage-
ways. Videolaryngoscopes have reduced the incidence ment12,13 but the indications and pattern of using video-
of emergency surgical airway management in the peri- laryngoscopy in daily practice are currently unknown.14

From the Department of Anesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem (AA, YS, AC,
CW) and Intensive Care Unit, Shaarei Zedek Medical Center, Jerusalem, Israel (PDL)
Correspondence to Alexander Avidan, Department of Anesthesiology, Critical Care and Pain, Hadassah Medical Center, Ein Karem, POB 12000, Jerusalem 9112001,
Israel
E-mail: alex@avidan.co.il

0265-0215 Copyright ß 2020 European Society of Anaesthesiology. All rights reserved. DOI:10.1097/EJA.0000000000001199

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 444 Avidan et al.

The goal of this retrospective cohort study was to ascer- cervical disorder (such as cervical injuries, previous cer-
tain whether the introduction of the GlideScope AVL vical surgery or other diseases), or limited mouth opening.
(Verathon Inc., Seattle, Washington, USA) in a tertiary
Finally, quarterly data on techniques used for all tracheal
academic referral centre led to changes in the frequency
intubations during a 10-year period (from February 2007
of use of flexible fibreoptic bronchoscopy or other
to February 2017, 4 years before and 6 years after the
methods of difficult airway management in adult
introduction of the GlideScope) were retrieved from the
patients undergoing general anaesthesia with tracheal
anaesthesia information management system in order to
intubation with expected or unexpected difficult intu-
analyse temporal changes.
bation, a history of difficult intubation or with cervical
disorder or limited mouth opening. Additionally, we Intubation techniques used for difficult airway manage-
investigated whether there was a change in frequency ment were divided into three groups: GlideScope, flexi-
of cases with impossible intubation after the introduc- ble fibreoptic bronchoscopy or other difficult airway
tion of the GlideScope. management devices [including Truview evo2 laryngo-
scope blade (Truphatek, Israel), Airtraq (Prodol Meditec,
The Glidescope is a videolaryngoscope including a light
Spain), LMA Fastrach Re-usable (Teleflex Incorporated,
source and video camera at the distal end of a laryngo-
Ireland) (with subsequent blind intubation or with use of
scope blade transmitting a real-time picture to a separate
flexible fibreoptic bronchoscopy)].
screen. Similar types of videolaryngoscopes are available
from several other manufacturers.
Statistical analysis
We hypothesised that the introduction of videolaryngo-
The proportion of nondirect laryngoscopy intubations
scopy reduced the use of flexible fibreoptic bronchoscopy
during the periods before and after the introduction of
and other methods of airway management and that cases
the GlideScope were compared. Among nondirect laryn-
of impossible tracheal intubation were markedly reduced.
goscopy techniques, patient characteristics were com-
pared for the periods before and after the introduction
of the GlideScope. Differences were sought between the
Methods
two periods in the proportion of cases employing flexible
Ethical approvals for this study with waiver for informed
fibreoptic bronchoscopy, both for awake and anaesthe-
consent was provided by the Institutional Review Board
tised patients. Similarly, the use of difficult airway man-
of the Hadassah Medical Organisation, POB 12000, Jer-
agement techniques other than flexible fibreoptic
usalem, 91120, Israel (Ref: HMO-13–0007, approval date
bronchoscopy was compared. Quarterly use of the various
4 March 2013 and HMO-11–0316, approval date 30
techniques was analysed over a 10-year period.
November 2015, Chairperson Professor T. Chajek).
Proportions were compared using Fisher’s exact or Pear-
Initially, data on all techniques of tracheal intubation in son’s x2-square test, as appropriate. Means were com-
adults (18 years of age) were retrieved from the anaes- pared with paired t-tests. P < 0.05 was considered
thesia information management system (Metavision, statistically significant. Regression analyses evaluated
iMDsoft, Tel Aviv, Israel) for equal periods prior to changes in mean quarterly use over the 10-year period
introduction of the GlideScope (from 19 July 2009 until of each of the techniques for difficult intubation before
27 April 2011) and thereafter (28 April 2011 to 3 February and after the introduction of the GlideScope. Statistical
2013, start of retrospective data collection). Each period analyses were performed with SAS Version 9.2 (SAS
was 647 days long. Patients having tracheal intubation Institute, Cary, North Carolina, USA), WinPepi Version
performed with a nondirect laryngoscopic technique (see 11.6515 and Microsoft Excel 365 (Microsoft, Redmond,
below) and patients with failed tracheal intubation were USA).
then identified in order to calculate the frequencies of
each of these techniques as a proportion of all patients Results
undergoing tracheal intubation. During the period before the introduction of the Glide-
The following data were retrieved from the anaesthesia Scope 8306, patients underwent tracheal intubation,
compared with 8517 during the period after the Glide-
information management system: age, sex, ASA physical
status classification system, weight, intubation technique Scope introduction. Patients’ characteristics were very
similar in both periods (Table 1). During the period
and whether tracheal intubation failed. For patients
intubated employing a nondirect laryngoscopy tech- before the introduction of the GlideScope, a difficult
airway management technique was used for 235/8306
nique, data on whether intubation was expected to be
easy or difficult or unexpectedly difficult were retrieved. (2.8%) patients versus 480/8517 (5.6%) patients after
its introduction (P < 0.0001). There were no differences
From the Hadassah hospital information system, the in the percentage of patients in whom a difficult airway
following information was gathered: expected or known management method was used for expected or unex-
history of difficult intubation, past or current history of pected difficult intubation, for patients with limited

Eur J Anaesthesiol 2020; 37:443–450

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 Effect of introduction of GlideScope on difficult airway management 445

Table 1 Summary of patient characteristics

All patients with tracheal intubation Patients intubated using a method for difficult airway management
Before Glidescope After Glidescope Before Glidescope After Glidescope
(19 July 2009 to 27 (28 March 2011 to 3 (19 July 2009 to (28 March 2011 to
March 2011, 947 days February 2013, 947 days) P 27 March 2011, 947 days 3 February 2013, 947 days) P
All patients 8306 8517 235 480
Female 4339 (52.5) 4423 (51.9) 0.689 141 (60.0) 273 (56.9) 0.468
Male 3967 (47.8) 4094 (48.1) 94 (40.0) 207 (43.1)
Age (years) 50.6  18.6 50.5  18.6 0.098 52.6  17.5 54.5  16.8 0.362
Weight (kg) 76.6  18.4 76.7  18.8 0.362 82.7  25.4 84.4  22.0 0.098
Elective 6968 (83.3) 7029 (82.5) 0.018 226 (96.2) 395 (82.3) <0.0001
Emergency 1338 (16.7) 1488 (18.5) 9 (3.8) 85 (17.7)
ASA physical status, including emergency cases
1 2363 (28.4) 2273 (26.7) 0.011 44 (18.7) 66 (13.8) 0.098
2 3942 (47.5) 4171 (49.0) 0.050 122 (51.9) 265 (55.2) 0.425
3 1697 (20.4) 1738 (20.4) 0.968 67 (28.5) 129 (26.9) 0.656
4 298 (3.6) 325 (3.8) 0.433 2 (0.9) 20 (4.2) 0.019
5 6 (0.1) 10 (0.1) 0.342 – – –

Values are mean  SD or number of patients (% of total).

mouth opening or for patients who had a previous history GlideScope 29/8517 (0.34%), P ¼ 0.862]. The changes
of difficult intubation (Table 2). After introduction of the in use of flexible fibreoptic bronchoscopy, GlideScope
GlideScope, a higher proportion of patients with cervical and other devices for the different indications before and
disorder and unknown or other indications (such as after the introduction of the GlideScope are summarised
obstruction or deviation of the glottic or subglottic area in Table 2.
because of a tumour or other disease) underwent intuba-
tion with a nondirect laryngoscopic technique than before The overall use of flexible fibreoptic bronchoscopy
the introduction of the GlideScope. There was no differ- decreased by 44.4% after the introduction of the Glide-
ence in the proportion of intubations performed with Scope [before GlideScope 149/8306 (1.8%); after Glide-
flexible fibreoptic bronchoscopy for cervical disorders and Scope 85/8517 (1.0%), P < 0.0001) (Table 3)]. This
unknown/other reason between the two periods [cervical reduction was found for both awake patients and patients
disorder: before GlideScope: 16/8306 (0.19%), after under general anaesthesia [awake: before GlideScope
GlideScope: 12/8517 (0.14%), P ¼ 0.410; unknown/other 110/8306 (1.3%); after GlideScope 62/8517 (0.7%), a
reasons: before GlideScope: 27/8306 (0.33%), after 43.8% reduction, P < 0.001; under general anaesthesia:

Table 2 Changes of indications for use of techniques for difficult intubation before and after introduction of the GlideScope

Before introduction N U 8306 After introduction N U 8517 % Change P

Expected difficult intubation 66 (0.79) 74 (0.87) 0.596
Flexible fibreoptic bronchoscopy 48 (0.58) 17 (0.20) 65.5% <0.0001
Other devices 18 (0.22) 8 (0.09) 56.7% 0.043
GlideScope – 49 (0.58)
Unexpected difficult intubation 54 (0.65) 68 (0.80) 0.257
Flexible fibreoptic bronchoscopy 26 (0.31) 5 (0.06) 81.2% <0.0001
Other devices 28 (0.34) 5 (0.06) 82.6% <0.0001
GlideScope – 58 (0.7)
Limited mouth opening 21 (0.25) 32 (0.38) 0.155
Flexible fibreoptic bronchoscopy 18 (0.22) 19 (0.22) 2.9% 0.93
Other devices 3 (0.04) 1 (0.01) 67.5% 0.305
GlideScope – 12 (0.14)
Cervical disorder 22 (0.26) 48 (0.58) 0.0026
Flexible fibreoptic bronchoscopy 16 (0.19) 12 (0.14) 25.0% 0.41
Other devices 6 (0.07) 2 (0.02) 67.5% 0.147
GlideScope – 34 (0.41)
History of difficult intubation 17 (0.20) 12 (0.14) 0.319
Flexible fibreoptic bronchoscopy 14 (0.17) 3 (0.04) 78.6% 0.006
Other devices 3 (0.04) 0 100.0% 0.246
GlideScope – 9 (0.11)
Unknown/other 53 (0.64) 244 (2.94) <0.0001
Flexible fibreoptic bronchoscopy 27 (0.33) 29 (0.35) 7.4% <0.0001
Other devices 26 (0.31) 6 (0.07) 76.9% <0.0001
GlideScope – 209 (2.52)

Values are number of patients (% of N).

Eur J Anaesthesiol 2020; 37:443–450

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 446 Avidan et al.

Table 3 Comparison of the use of fibreoptic bronchoscopy and other devices for difficult intubation before and after introduction of the
Glidescope

Reason Before introduction (N U 8306) After introduction (N U 8517) % Change P

Fibreoptic bronchoscopy: total
Expected difficult intubation 48 (0.58) 17 (0.2) 65.5 <0.0001
Unexpected 26 (0.31) 5 (0.06) 80.6 <0.0001
Limited mouth opening 18 (0.22) 19 (0.22) 0 0.930
Cervical pathology 16 (0.19) 12 (0.14) 26.3 0.410
History of difficult intubation 14 (0.17) 3 (0.04) 78.9 0.0065
Other/unknown 27 (0.33) 29 (0.34) 3.0 0.862
Total 149 (1.79) 85 (1.0) 44.1 <0.0001
Fibreoptic bronchoscopy awake
Expected difficult intubation 38 (0.46) 9 (0.11) 76.1 <0.0001
Unexpected 7 (0.08) 0 100 0.0074
Limited mouth opening 16 (0.19) 18 (0.21) 10.5 0.787
Cervical pathology 16 (0.19) 12 (0.14) 26.3 0.410
History of difficult intubation 14 (0.17) 3 (0.04) 76.5 0.0065
Other/unknown 19 (0.23) 20 (0.23) 0 0.935
Total 110 (1.3) 62 (0.73) 43.8 0.0001
Fibreoptic bronchoscopy under general anaesthesia
Expected difficult intubation 10 (0.12) 8 (0.09) 25.0 0.6
Unexpected 19 (0.23) 5 (0.06) 73.9 0.0035
Limited mouth opening 2 (0.02) 1 (0.01) 50.0 0.549
Cervical pathology 0 0
History of difficult intubation 0 0
Other/unknown 8 (0.1) 9 (0.11) 10.0 0.849
Total 39 (0.47) 23 (0.27) 42.6 0.033
Other devices
Expected difficult intubation 18 (0.22) 8 (0.09) 59.1 0.043
Unexpected 28 (0.34) 5 (0.06) 82.4 <0.0001
Limited mouth opening 3 (0.04) 1 (0.01) 75.0 0.305
Cervical pathology 6 (0.07) 2 (0.02) 71.4 0.147
History of difficult intubation 3 (0.04) 0 100 0.079
Other/unknown 26 (0.31) 6 (0.07) 77.4 0.0003
Total 84 (1.0) 22 (0.3) 70.0 <0.0001

Values are number of patients (% of total).

before GlideScope 39/8306 (0.47%); after GlideScope 27/ reduced in patients with expected or unexpected difficult
8517 (0.27%), a 42.6% reduction, P ¼ 0.006). There was intubation and unknown or other reasons (Table 3).
also a significant decrease in use of other nondirect
laryngoscopy intubation equipment after the introduc- The quarterly use of flexible fibreoptic bronchoscopy
tion of the GlideScope [before GlideScope 84/8306 and other techniques for tracheal intubation during a
(1.0%); after GlideScope 22/8517 (0.26%), a 70% 10-year period is shown in Fig. 1 (including 4 years
decrease, P < 0.0001]. There was no difference in the before and 6 years after the introduction of the Glide-
number of impossible tracheal intubations between the Scope). The percentage of patients intubated with
two periods (before GlideScope 2/8306 (0.02%), after flexible fibreoptic bronchoscopy per quarter was higher
GlideScope 2/8517 (0.02%), P ¼ 0.98). before the introduction of the GlideScope than after its
introduction [before: 1.9  0.5 (95% CI, 1.7 to 2.1)
After introducing the GlideScope, the use of flexible patients per quarter versus after 1.0  0.3 (95%, CI
fibreoptic bronchoscopy in awake patients decreased 0.8 to 1.1) (P < 0.0001)]. However, the absolute number
significantly among patients with expected and unex- of quarterly uses of flexible fibreoptic bronchoscopy
pected difficult intubation and among patients with a was stable during each period (before P ¼ 0.1646, after
history of difficult intubation (Table 3). The use of awake P ¼ 0.3019); this was true also for awake patients
flexible fibreoptic bronchoscopy remained stable for (before P ¼ 0.2132, after P ¼ 0.9878) and patients
patients with limited mouth opening, cervical disorder under general anaesthesia (before P ¼ 0.2985, after
or with other and unknown reasons (Table 3). Use of P ¼ 0.1709). Quarterly proportional use of other devices
flexible fibreoptic bronchoscopy under general anaesthe- increased over time before the introduction of the
sia was significantly reduced in patients with unexpected GlideScope (P < 0.0001) but there was no change
difficult intubation, but not in patients with expected (P ¼ 0.2704) in the quarterly proportional use after its
difficult intubation, limited mouth opening and other and introduction. There was a steady and significant
unknown reasons (Table 3). increase in quarterly use of the GlideScope over time
After the GlideScope was introduced, the use of other in the 6 years after its introduction (P < 0.0001). The
difficult airway management techniques was significantly use of the GlideScope was disproportionately higher

Eur J Anaesthesiol 2020; 37:443–450

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 Effect of introduction of GlideScope on difficult airway management 447

Fig. 1

10%

9%

8%

7%

6%

5%

4%

3%

2%

1%

0%
2007/1
2007/2

2007/3
2007/4
2008/1
2008/2
2008/3
2008/4
2009/1
2009/2
2009/3

2009/4
2010/1
2010/2
2010/3
2010/4
2011/1
2011/2
2011/3
2011/4

2012/1
2012/2
2012/3
2012/4
2013/1
2013/2
2013/3
2013/4
2014/1

2014/2
2014/3
2014/4
2015/1
2015/2
2015/3
2015/4
2016/1
2016/2
2016/3
2016/4
2017/1
Flexible fibreoptic bronchoscopy Other devices for difficult intubation Glidescope

Quarterly use of devices for difficult intubation (February 2007 to February 2017) (total n¼48 346). Quarterly proportional use of flexible fibreoptic
bronchoscopy and other techniques for tracheal intubation during a 10-year period. Although the percentage of patients intubated with flexible
fibreoptic bronchoscopy per quarter was higher before than after the introduction of the GlideScope, the percentage of quarterly uses of flexible
fibreoptic bronchoscopy was stable during each period. The number of intubations performed with the GlideScope was disproportionately higher
than the reduction in use of flexible fibreoptic bronchoscopy and other techniques for difficult intubation, and increased over time.

than the reduction in use of flexible fibreoptic bron- Notably, this study demonstrated that videolaryngoscopy
choscopy and other devices. use was disproportionately greater than the prior use of
fibreoptic bronchoscopy and all other difficult airway
techniques (Fig. 1). This might be because of cases in
Discussion
which the GlideScope was used for resident teaching and
The results of this study supported our hypothesis that
these cases can be attributed to situations where the
introducing videolaryngoscopy into the operating rooms
indication for its use could not be determined (64% of
of a tertiary care university hospital was associated with
all GlideScope uses). An alternate explanation is that this
a 44% reduction in the use of flexible fibreoptic bron-
liberal use of videolaryngoscopy might be as it provided a
choscopy and a 70% decrease in the use of other difficult
feeling of security to anaesthesiologists managing sus-
airway management techniques. The diminished use of
pected or anticipated difficult intubations,3 without hav-
flexible fibreoptic bronchoscopy was especially marked
ing a real impact on outcome (the number of impossible
in cases of unexpected difficult intubation and those
intubations was equally low in both groups). Moreover,
with a history of difficult intubation. However, there
we assume that it is more comfortable for a patient with
was almost no change in the use of flexible fibreoptic
suspected difficult intubation to be intubated with a
bronchoscopy in cases of limited mouth opening and
videolaryngoscope while under general anaesthesia than
other or unknown reasons. This latter group of patients
awake with flexible fibreoptic bronchoscopy.
explained the reduced, but stable, quarterly use of
fibreoptic intubations after the introduction of videolar- Although there was a 26% reduction in the use of flexible
yngoscopy (Fig. 1). fibreoptic bronchoscopy for patients with cervical

Eur J Anaesthesiol 2020; 37:443–450

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 448 Avidan et al.

disorders, the proportion of patients with reported by Benumof.22 In contrast, Lee et al.23 reported that the
cervical disorders was higher in the period before than Trachway video stilette (Biotronic Instrument Enterprise
after the introduction of the GlideScope. In more than Ltd., Tai-Chung, Taiwan), which more resembles a rigid
two-thirds of the patients with cervical disorder in the fibreoptic bronchoscope than a classical videolaryngo-
period after the introduction of the GlideScope, video- scope, could replace fibreoptic intubation in cases of
laryngoscopy was used for tracheal intubation. How- awake intubation in patients with limited mouth
ever, there was no difference in the proportion of opening.
flexible fibreoptic bronchoscopy use among the patients
Trainees should acquire sufficient experience to ensure
before and after the introduction of GlideScope. This is
proficiency in the various difficult airway management
probably attributable to the use of direct laryngoscopy
techniques. Learning to use the flexible fibreoptic bron-
with axial traction and manual inline stabilisation
choscope for intubation is a cornerstone of resident
among patients prior to the introduction of the Glide-
training in anaesthesia.24 However, teaching difficult
Scope with only suspected or minor cervical disor-
airway management raises challenging ethical issues.25
ders.16 The number of such patients could not be
The patient’s right to receive the best treatment available
identified as such cases were reported in the anaesthe-
and the right of informed consent must be weighed
sia information management system as ‘direct laryngos-
against the need to train residents and having attending
copy’ without any notation of cervical disorder or axial
anaesthesiologists maintain high levels of professional
traction and inline stabilisation.
skill. The replacement of flexible fibreoptic bronchos-
Liberal use of a videolaryngoscope with single-use dis- copy by videolaryngoscopy in half of the cases with
posable blades results in higher costs. The single-use expected or unexpected difficult intubation substantially
metal Macintosh blade used in our department costs reduces the training opportunities for residents.26
approximately s3.00 and the GlideScope single-use Although there is a high success rate in awake fibreoptic
blade about s24.50. On the basis of the data from the intubation during the first experience of supervised trai-
anaesthesia information management system for 2017, nees,27 many attempts in a simulator are necessary to gain
this increased costs by about s8200/year (the GlideScope proficiency in fibreoptic intubation.28 Fibreoptic intuba-
was used for 8% of tracheal intubations). In contrast, the tion simulators are available and recommended for train-
annual costs of using reusable flexible fibreoptic broncho- ing,29–32 but transfer of skills acquired with such
scopes (including purchase, repairs and handling/clean- simulators into clinical practice is questioned.33
ing per case) are high and estimated at s18200.17 The
The strength of this study is that it used a large
approximately 50% reduction in flexible fibreoptic bron-
database to examine the effects of adding videolaryn-
choscopy observed in our study would lead to a yearly
goscopy to the anaesthesia activities of a large tertiary
saving of about s9100.
care medical centre. It clearly demonstrates that,
Although it is questioned whether flexible fibreoptic unlike other difficult intubation methods, this technol-
bronchoscopy is still considered the gold standard for ogy had major effects on daily practice. However, the
managing difficult intubation,18 Popat and Woodall19 study, being retrospective, was not designed to exam-
showed that awake fibreoptic intubation is underuti- ine outcomes (reduced morbidity and mortality) or
lised and that the threshold for using this technique cost-effectiveness.
should be lowered. As this study showed, videolaryn-
Both before and after the introduction of the Glide-
goscopy replaced fibreoptic intubation in cases of
Scope, there were only two cases of impossible intuba-
expected and unexpected difficult intubation, but in
tion. It seems that even with the addition of
patients with limited mouth opening, fibreoptic intu-
videolaryngoscopy to the difficult intubation armamen-
bation was still the first choice. Law et al.20 reviewed 12
tarium, there are situations in which tracheal intubation
years of practice and showed no reduction in the
was still impossible. However, in the anaesthesia infor-
incidence of awake fibreoptic intubations despite the
mation management system, only the final airway
introduction of videolaryngoscopes. Unfortunately,
management technique was noted so that it likely
they did not study the indications for the use of awake
that there were more patients with failed tracheal
intubation. Wanderer et al.21 found similar results
intubation who were ventilated with a laryngeal mask
(decreased fibreoptic intubations, a disproportionate
airway as a rescue technique. In such cases, the laryn-
increase in the use of videolaryngoscopy) but did
geal mask airway would have been marked in the
neither report the reasons why videolaryngoscopy
anaesthesia information management system as the
replaced fibreoptic intubation nor the indications for
airway management technique, and thus not included
the continued use of fibreoptic intubation.
in the number of cases of impossible tracheal intuba-
Our study showed that in cases of limited mouth opening tion. However, in our experience, the number of such
and cervical spine injuries, awake fibreoptic intubation cases is very low. Additionally, we do not know in how
can still be regarded as the gold standard, as emphasised many cases flexible fibreoptic bronchoscopy was used

Eur J Anaesthesiol 2020; 37:443–450

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 Effect of introduction of GlideScope on difficult airway management 449

after failed intubation with the GlideScope or vice 4 Kory P, Guevarra K, Mathew JP, et al. The impact of video laryngoscopy use
during urgent endotracheal intubation in the critically ill. Anesth Analg
versa. 2013; 117:144–149.
5 Sakles JC, Mosier J, Chiu S, et al. A comparison of the C-MAC
Another limitation of this study is that it is retrospective, video laryngoscope to the Macintosh direct laryngoscope for
so that the choice of a specific technique for difficult intubation in the emergency department. Ann Emerg Med 2012;
60:739 – 748.
intubation could not always be established because of 6 Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015
missing or difficult-to-interpret data. A patient may have guidelines for management of unanticipated difficult intubation in adults. Br
been assessed preoperatively as a potential difficult intu- J Anaesth 2015; 115:827–848.
7 Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists’
bation, but the anaesthesiologists performing the intuba- Association and Difficult Airway Society guidelines for the management of
tion may have estimated the patient as being an easy difficult and failed tracheal intubation in obstetrics. Anaesthesia 2015;
intubation or vice versa. Another limitation is that this 70:1286–1306.
8 Fei M, Wanderer JP, Jiang Y, et al. Association between the availability
was a single-centre study and it is possible that in hospi- of videolaryngoscopes and the incidence of emergency surgical
tals with different case mixes and departmental airway in the perioperative setting of a large academic medical
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