Flexible bronchoscope versus video-laryngoscope for nasotracheal intubation in patients with anticipated difficult airway under topical anesthesia and dexmedetomidine infusion: A randomized controlled trial

Background: Managing difficult airways with restricted mouth opening remains a challenge. In this regard, flexible bronchoscopes (FB) are considered the gold standard, offering precise tube placement. However, they require expertise and can be time-consuming. Video-laryngoscopes (VLs), such as the CMAC D-blade, provide enhanced glottic visualization and may reduce intubation time. While VLs are gaining popularity, data comparing them with FBs in this setting are limited. This study evaluates whether the CMAC D-blade VL can reduce intubation time compared to FB while maintaining similar success rates. Methods: In this randomized controlled trial, 100 adult patients scheduled for elective head and neck or oral and maxillofacial surgery with anticipated difficult airways were randomized to receive awake nasotracheal intubation using either an FB or CMAC D-blade VL. The primary outcome was intubation time. Secondary outcomes included first-attempt success rate, overall success rate, and satisfaction scores. Results: Out of 100 patients, 97 patients completed the study (FB: n = 49, VL: n = 48). Median intubation time was significantly shorter in the VL group (62 [53-71] sec) compared to the FB group (118 [107-134] sec; p < 0.0001). Success rates and intubation scores were similar, but anesthesiologist and patient satisfaction scores were better in the FB group. Conclusion: The CMAC D blade video-laryngoscope reduces intubation time while maintaining similar success rates compared to the flexible bronchoscope for awake nasotracheal intubation with limited mouth opening. Despite the time advantage, the flexible bronchoscope was preferred by anesthesiologists and patients had more comfort.