Anaesthesia 2018 doi:10.1111/anae.

14299

Review Article
Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal
intubation: a systematic review and meta-analysis
M. Alhomary,1 E. Ramadan,2 E. Curran3 and S. R. Walsh4

1 Registrar, Department of Anaesthesia, Northshore Hospital, Auckland, New Zealand

2 Registrar, 3 Consultant, Department of Anaesthesia, University Hospital Galway, Galway
4 Consultant, Department of Vascular Surgery, National University of Ireland, Galway, Ireland

Summary
Awake fibreoptic intubation is often considered the technique of choice when a difficult airway is anticipated. How-
ever, videolaryngoscopes are being used more commonly. We searched the current literature and performed a meta-
analysis to compare the use of videolaryngoscopy and fibreoptic bronchoscopy for awake tracheal intubation. Our
primary outcome was the time needed to intubate the patient’s trachea. Secondary outcomes included: failed intuba-
tion; the rate of successful intubation at the first attempt; patient-reported satisfaction with the technique; and any
complications resulting from intubation. Eight studies examining 429 patients were included in this review. The intu-
bation time was shorter when videolaryngoscopy was used instead of fibreoptic bronchoscopy (seven trials, 408 par-
ticipants, mean difference (95%CI) 45.7 ( 66.0 to 25.4) s, p < 0.0001, low-quality evidence). There was no
significant difference between the two techniques in the failure rate (six studies, 355 participants, risk ratio (95%CI)
1.01 (0.24–4.35), p = 0.99, low-quality evidence) or the first-attempt success rate (six studies, 391 participants, risk
ratio (95%CI) 1.01 (0.95–1.06), p = 0.8, moderate quality evidence). The level of patient satisfaction was similar
between both groups. No difference was found in two reported adverse events: hoarseness/sore throat (three studies,
167 participants, risk ratio (95%CI) 1.07 (0.62–1.85), p = 0.81, low-quality evidence), and low oxygen saturation (five
studies, 337 participants, risk ratio (95%CI) 0.49 (0.22–1.12), p = 0.09, low-quality evidence). In summary, video-
laryngoscopy for awake tracheal intubation is associated with a shorter intubation time. It also seems to have a suc-
cess rate and safety profile comparable to fibreoptic bronchoscopy.
.................................................................................................................................................................
Correspondence to: M. Alhomary
Email: mohamed.alhomary@gmail.com
Accepted: 2 March 2018
Keywords: airway management; awake tracheal intubation; systematic review; videolaryngoscopy

Introduction nasal bleeding, over-sedation, airway hyper-reactivity

Awake fibreoptic intubation is widely advocated for
the management of the known or anticipated difficult
airway [1]. However, fibreoptic intubation can be a
challenging technique to learn, and continuous practice
is needed to maintain the skill [2]. Additionally, there
are risks associated with this procedure, including
and complete airway obstruction [3–5]. The technique
also requires adequate equipment and patient prepara-
tion and usually takes a considerable amount of time
to be performed. All these factors have led to the
underuse of fibreoptic intubation by many anaes-
thetists.

© 2018 The Association of Anaesthetists of Great Britain and Ireland 1

Anaesthesia 2018 Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation
In a recent prospective study, awake fibreoptic intu-
bation was performed in 1.71% of patients presenting
for surgery under general anaesthesia [6]. The success
rate reported was 99%, and the overall complication
rate was 11%. In addition, this study demonstrated a
significant negative correlation between the number of
previous awake fibreoptic intubations performed by the
anaesthetist and the incidence of complications. This
underlines how continued training in awake fibreoptic
intubation is essential to maintaining the safety of this
technique.
Videolaryngoscopes, on the other hand, are
increasing in popularity and are slowly becoming the
preferred tool for the management of the difficult air-
way. They seem to be easier to use and quicker to learn.
Heidegger et al. described that anaesthetists need
around 25 intubations to be competent with fibreoptic
intubation [3], whereas only one to six intubations are
needed to reach the same level of competence with
videolaryngoscopy [7, 8].
There are some potential advantages of videolaryngo-
scopes over fibreoptic bronchoscopes. First, they provide
a wider view of the airway, which results in a better view
of nearby structures [9]. Second, there is no limitation on
the tracheal tube diameter which may be used, in contrast
to fibreoptic bronchoscopes, when smaller size tracheal
tubes cannot be used. Finally, it is easier to change the
size of the tracheal tube if required while maintaining the
airway view. This differs from the fibreoptic technique,
which requires the removal of the fibrescope from the
patient’s airway in order to make this change.
However, the use of videolaryngoscopes for awake
intubation is a relatively new technique. It is unclear
whether they truly provide advantages over fibreoptic
intubation. With the aim of summarising the available
literature, we conducted this systematic review and
meta-analysis to compare videolaryngoscopy and
fibreoptic bronchoscopy for awake intubation.
Methods
This systematic review and meta-analysis were con-
ducted in accordance with the PRISMA guidelines
[10]. All authors agreed on the study protocol before
commencing the review.
We carried out a search until June 2017 in the
following electronic databases: the Cochrane Central
2 © 2018 The Association of Anaesthetists of Great Britain and Ireland
Register of Controlled Trials (CENTRAL); MEDLINE;
and Embase. The details of our search strategy can be
found in the Supporting Information (Appendix S1).
The reference lists of all eligible papers were hand-
searched for additional potential studies. We did not
restrict our search by language of publication. We dealt
with incomplete data by contacting the principal authors,
when possible, to ask for missing or unclear information.
Two reviewers (MA and EC or ER) independently
screened the articles by title and abstract according to
the predetermined inclusion criteria and excluded any
irrelevant or duplicate studies. Two authors then
examined the full texts of all potential trials to further
assess their eligibility for inclusion in this review. Any
disagreement between the authors was resolved by dis-
cussion or by consulting a fourth author (SW) to make
a final decision if consensus was not achieved.
We included only randomised controlled trials
comparing videolaryngoscopy with fibreoptic bron-
choscopy in patients requiring awake tracheal intuba-
tion. We excluded case reports, observational studies
and cross-over trials. Mannikin studies were not con-
sidered in this review, and we only accepted trials if
they reported intubation time as one of their out-
comes. Studies were included if they compared the use
of videolaryngoscopes of any model with the use of
fibreoptic flexible bronchoscopes. Participants were
patients of any age and sex who needed awake tracheal
intubation either via the nasal or oral route, regardless
of the indication and the surgical procedure.
Our primary outcome was the time needed to
intubate the trachea. Our secondary outcomes were:
failed intubation; the rate of successful intubation at
the first attempts; patient-reported satisfaction; and
any complications or adverse events resulting from
intubation.
The potential risk of bias in each included study
was assessed independently by two authors (MA and
EC or ER). We used the Cochrane Collaboration’s tool
[11] to evaluate the quality of each study design, con-
sidering the following possible sources of bias: random
sequence generation; allocation concealment; blinding
of participants, personnel and outcome assessors;
incomplete outcome data; and selective outcome
reporting. We also assessed the risk of bias that can
result from the level of experience of the anaesthetist
Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation
with the device used for tracheal intubation, as we felt
this could be an important confounding factor.
We used Review Manager (RevMan 5.3; Copen-
hagen: The Nordic Cochrane Centre, The Cochrane
Collaboration, 2014) for data analysis. For dichotomous
outcomes (e.g. failure rate, first-attempt success), we
calculated risk ratios (RR) with 95%CI, and for contin-
uous outcomes (e.g. intubation time), we used the
mean difference (MD). When the continuous outcome
was reported in some studies as median, range and
interquartile range, we estimated means and standard
deviations using the formula described by Hozo [12].
Risk ratios were calculated with the Mantel–Haen-
szel method using the random-effects model as we
expected clinical and methodological heterogeneity
between the studies. We evaluated the heterogeneity by
using the I2 statistic, with I2 levels of 25%, 50% and 75%
implying low, moderate and high degrees of heterogene-
ity, respectively. We carried out sub-group analyses for
the route of intubation and the design of videolaryngo-
scope to investigate the causes of significant heterogene-
ity. In addition, we undertook a post-hoc sensitivity
analysis by omitting certain studies from the data syn-
thesis to further explore the robustness of our results.
Visual inspection of funnel plots is often used to
assess for publication bias, as evidence of this can be
indicated by the presence of asymmetry in the scatter
plot. However, publication bias is only one reason for
funnel plot asymmetry, and other factors can con-
tribute to this asymmetry [13]. When funnel plot
asymmetry exists, this should further be determined
using statistically relevant analyses [14]. We intended
to investigate publication bias using the funnel plot
technique, with Egger’s regression when appropriate.
Finally, we applied the Grades of Recommenda-
tion, Assessment, Development, and Evaluation
(GRADE) system [15] using GRADEpro software
(https://gradepro.org) to rate the quality of evidence
for each of our primary and secondary outcomes, tak-
ing into account risk of bias, inconsistency, impreci-
sion and indirectness [16].
Results
In our initial electronic search, we identified 239
potential articles. No additional studies were detected
through manual scrutiny of reference lists of studies.
© 2018 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2018
After removal of duplicates, we screened 165 articles
by title and abstract for eligibility. From these studies,
we only included nine trials for full-text evaluation.
We excluded one additional article due to irrelevant
methodology (Fig. 1) [17].
Eight studies were eventually included in our
review [18–25]. We excluded one study from the
meta-analysis due to incomplete data reporting [23].
Table 1 presents the characteristics of included studies,
and Table S1 summarises the baseline characteristics
of participants.
A total number of 429 participants were included
in the eight studies. All participants were adult patients
with ASA physical status 1–3. None of the studies
investigated patients who required emergency intuba-
tions. Two studies included only obese patients sched-
uled for bariatric surgery [18, 23]. All intubations were
performed in operating theatres by anaesthetists with
variable expertise in both videolaryngoscopy and fibre-
optic techniques.
Five different types of videolaryngoscopes were
used: GlideScope™ in four studies [18, 21, 23, 25]; Bul-
lard™ laryngoscope [19]; McGrath series 5™ [24]; C-
MAC D-blade™ [20] and Pentax AWS™ [22] (each in
one study). Two types of fibreoptic bronchoscopes
were used; the Karl Storz fibrescope in two studies [20,
21] and the Olympus fibrescope in four studies [18,
19, 22, 25]. Two studies did not specify the type of
fibreoptic bronchoscope used [23, 24]. In most of the
included studies, intubations were performed via the
oral route. Only in two studies was the nasal route
used for intubation [20, 21].
According to our assessment, the majority of the
studies had a low risk of selection, attrition and selec-
tive reporting biases. Blinding of participants, person-
nel and outcome assessors was not possible due to the
nature of the intervention. Most of the studies
reported in detail the number of previous intubations
performed with each device, so we rated these studies
as being at low risk of bias. The anaesthetists studied
by Cohn et al. [19] had performed at least 10 previous
intubations with videolaryngoscopy and fibreoptic
bronchoscopy; we felt that this number would favour
the videolaryngoscopy group. A summary of the risk
of bias for each included study is shown in Figure 2.
Publication bias was not assessed because the number
3
Anaesthesia 2018 Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation

Records identified through database Additional records identified through

Identification

searching other sources

(n = 239) (n = 0)

Records after duplicates removed

(n = 165)
Screening

Records screened Records excluded

(n = 165) (n = 156)

Full-text articles assessed for Full-text articles excluded

eligibility (n = 1)
(n = 9) Irrelevant methodology
Eligibility

Studies included in
qualitative synthesis
(n = 8)
Included

Studies included in
quantitative synthesis (meta-
analysis)
(n = 7)

Figure 1 Study flow diagram of included and excluded studies.

of included studies was insufficient to explore a funnel
plot or use more advanced regression-based assess-
ments appropriately.
All studies reported intubation times. However,
one study reported only the adjusted difference in
mean time for intubation between the two groups with
no further details [23], and for this reason, we could
not include this study in the meta-analysis. Our analy-
sis of the remaining seven studies showed that video-
laryngoscopy resulted in a shorter intubation time
compared with fibreoptic bronchoscopy (Fig. 3). How-
ever, we detected a marked degree of heterogeneity
between the studies (I2 = 94%). This significant
heterogeneity did not improve when we performed
sub-group analyses by the type of videolaryngoscope
used or the route of tracheal intubation. We were able
only to combine the trials that used the GlideScope, as
each of the remaining studies investigated a different
videolaryngoscope design. To further explore potential
causes of this high heterogeneity, we performed a sen-
sitivity analysis by omitting two studies from our
pooled data synthesis [22, 25]. The results of this anal-
ysis demonstrated a shorter intubation time in the
videolaryngoscopy group compared with the fibreoptic

4 © 2018 The Association of Anaesthetists of Great Britain and Ireland

 Table 1 Characteristics of included studies.

Study Device Participants (n) Inclusion criteria Exclusion criteria Interventions Outcomes
Cohn et al. Bullard VL: 8 Adults; ASA 1–3; risk No details Oral intubation; fentanyl, Time to glottic
[19] FB: 9 of neurological injury midazolam and droperidol visualisation; time to
Surgical (radicular symptoms, for sedation; topical intubate the trachea;
correction of request for awake anaesthesia with lidocaine failure rate
cervical spine intubation by
problem neurosurgeon)
Rosenstock McGrath VL: 48 Adults; ASA 1, 2, Age less than 18; Oral intubation; Intubation time;
et al. [24] FB: 45 3; modified SARI ASA 4, 5; mouth premedication with first-attempt success
Elective score ≥ 4; requiring opening less than glycopyrrolate; rate; number of
gynaecology, oral intubation for GA 15 mm; poor remifentanil infusion intubation attempts;
urology, ENT and dentition; surgeon’s and a bolus of glottic view; ease of
abdominal surgery request for nasal remifentanil or propofol; the technique
intubation; target Ramsay score of (VAS 0–10);
contraindication to 2–4; topical anaesthesia complications;

© 2018 The Association of Anaesthetists of Great Britain and Ireland

trans-tracheal injection with lidocaine; patient’s discomfort
trans-tracheal injection (VAS 0–10)
Wahba et al. GlideScope VL: 25 Adults; ASA 1-3 BMI ≥ 35; obstructive Oral intubation; Intubation time;
[25] FB: 25 airway disease; premedication with number of intubation
Cervical spine cardiovascular glycopyrrolate; sedation attempts; heart rate;
fixation disease; apparent with midazolam and mean arterial
airway difficulty; remifentanil infusion; pressure; neurological
patient refusal topical anaesthesia with assessment;
lidocaine; MILS complications (sore
maintained during throat or hoarseness);
intubation patient satisfaction
(scale of 1–3)
Abdellatif GlideScope VL: 31 BMI > 40; EGRI > 4 Age < 18 or > 60; Oral intubation; Intubation time;
et al. [18] FB: 32 ASA > 4; severe premedication with number of intubation
Laparoscopic mental illness; glycopyrrolate; topical attempts; best glottic
Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation

bariatric surgery mouth opening of anaesthesia with lidocaine; view; response to

< 15 mm; poor dentition,
contraindications
to drugs used during
procedure, patient refusal
remifentanil TCI; target
Ramsay score of 3
procedure (scale of
1–3); sore throat/
hoarseness; patient
satisfaction (scale
of 1–3)

(continued)

5
Anaesthesia 2018
6
Table 1 (continued)

Study Device Participants (n) Inclusion criteria Exclusion criteria Interventions Outcomes
Kramer et al. C-MAC VL: 50 Surgical procedure Dental abscess; ASA ≥ 4 Nasal intubation; Intubation time; best
[20] D-blade FB: 50 requiring nasal midazolam and glottic view;
Anaesthesia 2018

Oral and intubation; age > 18 years; remifentanil infusion anaesthetist’s

maxillofacial mouth opening > 1.3 cm; ≥ 1 for sedation; lidocaine satisfaction (scale
surgery criterion for difficult airway: for topical anaesthesia of 1–6); vital signs
modified Mallampati of 4, before induction of
inter-incisor distance < 2.5 cm, anaesthesia and after
history of difficulty in intubation;
intubation, tumour or swelling complications
obscuring intubation
Mahran GlideScope VL: 27 Age 20–60; ASA 1, 2; Patient refusal; restricted Nasal intubation; Intubation time;
et al. [21] FB: 27 Mallampati 3, 4 mouth opening; premedication with first-attempt success
Surgery for bleeding tendency; glycopyrrolate; rate; glottic view; sore
oropharyngeal contraindications phenylephrine nasal throat two hours
cancer to nasal intubation drops; sedation with postoperatively
remifentanil infusion;
lidocaine for topical
anaesthesia; Ramsay
score of 3
Mendonca Pentax AWS VL: 20 Adults; high Mallampati Nasal intubation; Oral intubation; Intubation time;
et al. [22] FB: 20 score; limited neck age < 18; glycopyrrolate; procedure time;
Elective surgery extension; limited jaw pregnancy; mouth sedation with doses of midazolam,
protrusion; maintenance opening < 2.5 cm midazolam and remifentanil and
of neutral cervical remifentanil infusion; lidocaine; best glottic
spine is required lidocaine for topical view; ease of
anaesthesia; Ramsay procedure (VAS
score of 2–3 of 0–100); patient
comfort (VAS
of 0–100)
Moore et al. GlideScope VL: 5 SARI > 4 No details Oral intubation; Intubation time;
[23] FB: 6 premedication with number of intubation
Bariatric surgery glycopyrrolate; attempts; change in
topical anaesthesia heart rate during the
with lidocaine; procedure; difficulty
remifentanil infusion of procedure (VAS
and midazolam of 0–10); patient
for sedation satisfaction (VAS
of 0–10

EGRI, El-Ganzouri risk index; FB, fibreoptic bronchoscopy; GA, general anaesthesia; MILS, manual in-line stabilisation; SARI, simplified airway risk index; TCI, target-con-
trolled infusion; VAS, visual analogue scale; VL, videolaryngoscopy.
Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation

© 2018 The Association of Anaesthetists of Great Britain and Ireland

Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation
Figure 2 Risk of bias summary: authors’ judgements
about each risk of bias item for each included study.
Green, red and yellow circles indicate low, high and
unclear risk of bias, respectively.
bronchoscopy group, with reduced heterogeneity, the
mean difference (95%CI) being 22.51 ( 34.95 to
10.07) s, I2 = 42%, p = 0.0004.
Six studies [18–20, 22, 24, 25], with a total number
of 355 patients, provided details about the number of
failed intubations. All the studies defined failed intuba-
tion as the inability to intubate the trachea using the ini-
tially allocated technique. Analysis of data from these
studies (Fig. 4) demonstrated no significant difference
in the number of failed intubations between the groups.
© 2018 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2018
Similarly, analysis of the six studies (391 participants)
that reported on the number of successful intubations
on the first attempt [18, 20, 21, 24, 25] showed no
difference between the groups (Fig. 5).
Patient satisfaction was described in five studies.
Abdellatif et al. [18] reported that 58% of participants
rated their experience as excellent in the videolaryn-
goscopy group, compared with 59% in the fibreoptic
group (p = 0.92). Likewise, Wahba et al. [25] found
that 72% and 64% of patients described the procedure
as excellent in the videolaryngoscopy and fibreoptic
bronchoscopy groups, respectively (p > 0.05). In the
study by Mendonca et al. [22], the median visual ana-
logue scale (VAS) for patient comfort was 79 [range
59–100] in the videolaryngoscopy group compared
with 86 [range 69–100] in the fibreoptic bronchoscopy
group (p = 0.0616). Rosenstock et al. [24] reported an
equal level of patient discomfort during the procedure
in both groups, with a median [range] VAS of 2 [0–10]
for the videolaryngoscopy group and 2 [0–6] for the
fibreoptic bronchoscopy group (p = 0.55). Moore et al.
[23] stated that no difference was found between the
groups, but no further information was available. It was
not possible to combine the data of patient satisfaction
by meta-analysis due to the variability in the scoring
methods used to examine this outcome.
Three studies reported on hoarseness and/or sore
throat (Fig. 6) [18, 21, 25]. Two studies described an
equal incidence of minor nasopharyngeal bleeding in
the videolaryngoscopy and fibreoptic bronchoscopy
groups [20, 24]. Peripheral oxygen saturation of less
than 90% was described in five studies [18, 20, 22, 24,
25] with no significant difference in incidence between
the two groups. The pooled RR was 0.45, 95%CI 0.22–
1.12 (Fig. 7).
Due to study limitations, inconsistency and the
small number of participants, we found the quality of
evidence in relation to our main outcomes to be of
low quality. See Table S2 in the Supporting Informa-
tion for more details.
Discussion
This systematic review was designed to investigate the
efficacy and safety of videolaryngoscopy compared
with fibreoptic bronchoscopy for awake tracheal
intubation.
7
Anaesthesia 2018 Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation

Figure 3 Forest plot for the comparison of intubation time between videolaryngoscopy and fibreoptic bronchoscopy
groups. FB, fibreoptic bronchoscopy; IV, inverse variance; VL, videolaryngoscopy.

Figure 4 Forest plot for the comparison of failed intubation between videolaryngoscopy and fibreoptic bronchoscopy
groups. FB, fibreoptic bronchoscopy; M-H, Mantel–Haenszel; VL, videolaryngoscopy.

Figure 5 Forest plot for the comparison of first-attempt success between videolaryngoscopy and fibreoptic bron-
choscopy groups. FB, fibreoptic bronchoscopy; M-H, Mantel–Haenszel; VL, videolaryngoscopy.

The intubation time was our primary outcome
investigated; the pooled data analysis demonstrated
that the use of videolaryngoscopy is probably associ-
ated with a shorter intubation time compared with
fibreoptic bronchoscopy. However, a high degree of
heterogeneity was detected between the studies. Sub-
group analysis by the type of videolaryngoscope or
the route of intubation did not explain this hetero-
geneity. We found no significant difference between
the two techniques with regard to our secondary

8 © 2018 The Association of Anaesthetists of Great Britain and Ireland

Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation Anaesthesia 2018

Figure 6 Forest plot for the comparison of sore throat/hoarseness between videolaryngoscopy and fibreoptic bron-
choscopy groups. FB, fibreoptic bronchoscopy; M-H, Mantel–Haenszel; VL, videolaryngoscopy.

Figure 7 Forest plot for the comparison of oxygen saturation less than 90% between videolaryngoscopy and fibreop-
tic bronchoscopy groups. FB, fibreoptic bronchoscopy; M-H, Mantel–Haenszel; VL, videolaryngoscopy.

outcomes of failed intubation, first-attempt success
rate, patient satisfaction or complications related to
intubation.
Several possible factors may explain the high level
of heterogeneity detected. First, although all studies
recruited participants with known or predicted difficult
airway, the criteria used to assess this varied consider-
ably in different studies. For example, Cohn et al. and
Wahba et al. included patients with cervical spine dis-
ease and traumatic cervical spine injury, respectively
(which indicates a requirement to maintain neutral
cervical spine position during intubation) [19, 25].
This is in contrast to the more robust criterion (sim-
plified airway risk index) used by Abdellatif et al.,
Moore et al. and Rosenstock et al. [18, 23, 24], which
takes into consideration multiple factors such as
mouth opening, neck movement, weight, thyromental
distance and a previous history of difficulty in intuba-
tion. Second, our review included patients of different
populations in different clinical settings, from obese
patients for bariatric surgery to patients with oropha-
ryngeal cancer requiring maxillofacial procedures.
However, this diversity of types of patient potentially
contributes to the generalisability of the results. Finally,
the definition of intubation time was different between
studies and various points of time were used to assess
this outcome.
In our sensitivity analysis, we omitted the study by
Wahba et al. as they did not include patients with
apparent airway difficulty in their research [25].
Although cervical spine immobility can make intuba-
tion more challenging, it has been shown that video-
laryngoscopes are associated with less cervical spine
movement [26–28]. These participants may have had
relatively easier airways and this may have accounted
for the shorter intubation times found in this study.
We also removed the trial by Mendonca et al. due to
different methodology [22]. The authors described a
‘spray as you go’ technique for providing topical
anaesthesia to the airway. This may explain why intu-
bation times noted in this trial were significantly
longer than those in the remaining studies. Further-
more, their sample size was not calculated to detect a
difference in intubation time, as their primary outcome
was the total procedure time (sedation time and intu-
bation time). The degree of inconsistency improved
following this sensitivity analysis and the results
demonstrated an effect estimate comparable to our

© 2018 The Association of Anaesthetists of Great Britain and Ireland 9

Anaesthesia 2018 Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation
primary analysis. However, as this was a post-hoc
analysis, we did not consider these findings in our
assessment of the quality of evidence.
A major limitation of our study is that we carried
out a meta-analysis on an outcome with high hetero-
geneity (intubation time). We believe that this hetero-
geneity may have resulted from the different
methodologies and clinical factors within the studies,
but we acknowledged this limitation, and we down-
graded the quality of the evidence accordingly.
Another limiting factor is the variation in the types of
videolaryngoscope used in different studies and our
inability to perform sufficient sub-group analysis. The
GlideScope was the only scope used in more than one
trial; the remaining studies used different models of
videolaryngoscope. This probably contributed to the
substantial heterogeneity between the studies, but simi-
larly, added to the generalisability of our results, as
various institutions and practitioners will choose to
use different types of videolaryngoscope in their rou-
tine practice.
Intubation times, particularly when they are short,
may not be of clinical importance. However, if intuba-
tion time is prolonged due to patient factors or the
anaesthetist’s level of experience, a further increase in
time can be critical, especially in anxious patients with
respiratory compromise and who are at increased risk
of loss of airway patency. Furthermore, intubation time
may also provide information about the ease of the
technique, although this is debatable. Finally, we can
argue that decreasing intubation time in awake, albeit
sedated, patients may be associated with less patient
discomfort, as it shortens the duration of a potentially
stressful procedure.
Patient satisfaction is an important outcome
because awake intubation can be uncomfortable and
requires an adequate level of sedation and topical
anaesthesia to be tolerated. However, patient satisfac-
tion can be difficult to define and is often influenced
by cultural, social and cognitive factors [29]. Examples
of attributes of care that have been shown to improve
patient satisfaction include shared decision making,
effective communication, information and respect [30,
31]. Although a significant difference in patient satis-
faction was not found between the videolaryngoscopy
and the fibreoptic bronchoscopy groups, these results
10
should be interpreted with caution for two possible
reasons. First, these studies were not powered to detect
a difference in patient satisfaction between the two
groups. Second, the awake intubation described in
these trials involved the use of various sedative agents
to facilitate the procedure; this can affect the ability of
patients to recall the procedure and to measure this
outcome reliably.
Our assessment demonstrated a low risk of bias in
most domains among the majority of the included
studies. However, the blinding of intubators and out-
come assessors was not possible, and this could be an
area of concern regarding our results. Another factor
was the experience of the anaesthetist who performed
the intubation. As most of the trials clearly quantified
the previous experience of the intubators with each
device, we believe this potential source of bias did not
affect the quality of evidence from this review.
Most studies in our review did not include
patients with limited mouth opening due to the poten-
tial difficulty in inserting the videolaryngoscope blade
into the airway in these patients [32, 33]. This makes
applying the results of our review to this group of
patients more difficult, although fibreoptic bron-
choscopy might be more appropriate in this setting. In
addition, all intubations were performed in elective
patients, and this precludes the generalisability of the
results to emergency intubations when anaesthetists
and patients can be under psychological and time
pressures.
To our knowledge, this is the first systematic
review to provide data on the use of videolaryngoscopy
for awake tracheal intubation. We did not find previ-
ous similar reports that we can compare for agreement
and disagreement with our results. It highlights the
value of videolaryngoscopy as an alternative to awake
fibreoptic intubation in carefully selected patients.
Videolaryngoscopes appear to be safe for awake intu-
bation, and can achieve overall and first-attempt suc-
cess rates comparable to fibreoptic bronchoscopy.
Furthermore, there is lower quality evidence that the
use of videolaryngoscopes can result in faster tracheal
intubations. Future research should focus on evaluating
awake videolaryngoscopy in non-elective environments
and explore patient satisfaction with awake videolaryn-
goscopy in more detail.
© 2018 The Association of Anaesthetists of Great Britain and Ireland
Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation
Acknowledgements
No external funding or competing interests declared.
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Anaesthesia 2018 Alhomary et al. | Videolaryngoscopy vs. fibreoptic bronchoscopy for awake tracheal intubation

33. Aziz MF, Bayman EO, van Tienderen MM, Todd MM, StAGE Table S1. Baseline characteristics of participants in
Investigator Group, Brambrink AM. Predictors of difficult vide-
olaryngoscopy with GlideScope(R) or C-MAC(R) with D-blade:
the included studies. Values are mean  SD, median
secondary analysis from a large comparative videolaryn- [range] or number, n.
goscopy trial. British Journal of Anaesthesia 2016; 117: 118– Table S2. Summary of findings for videolaryn-
23.
goscopy compared with fibreoptic bronchoscopy for
awake tracheal intubation.
Supporting Information
Appendix S1. Search strategy for electronic data-
Additional Supporting Information may be found in
bases.
the online version of this article:

12 © 2018 The Association of Anaesthetists of Great Britain and Ireland