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British Journal of Anaesthesia, 119 (5): 993–9 (2017)

doi: 10.1093/bja/aex272
Advance Access Publication Date: 14 September 2017
Respiration and the Airway

Comparison of the paediatric blade of the Pentax-AWS

and Ovassapian airway in fibreoptic tracheal
intubation in patients with limited mouth opening and
cervical spine immobilization by a semi-rigid neck
collar: a randomized controlled trial
D. H. Kim, J. Y. Yoo, S. Y. Ha and Y. J. Chae*
Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea

*Corresponding author. E-mail:

Background. We compared the performances of the paediatric blade of a Pentax Airway Scope and an Ovassapian airway in
fibreoptic tracheal intubation in patients whose necks were stabilized by semi-rigid neck collars.
Methods. Ninety patients were enrolled in this prospective, open-label, randomized controlled trial. Patients were randomly
allocated to one of two groups (Group OVA-FOB and Group AWS-FOB). The time to tracheal intubation, success rate of tra-
cheal intubation, number of optimization manoeuvres (jaw thrust), and difficulty of manipulation of the fibreoptic broncho-
scope were compared between the groups.
Results. The time to tracheal intubation was significantly shorter (32 vs 50 s; median difference 19 s; 95% confidence interval
14–25 s; P<0.001) and manipulation of the fibreoptic bronchoscope was significantly easier for Group AWS-FOB.
Optimization manoeuvres were rarely required to facilitate fibreoptic tracheal intubation in Group AWS-FOB [jaw thrust, 0
(0%); jaw thrust with anterior neck collar removal, 1 (2%)] compared with that required in Group OVA-FOB [jaw thrust, 39
(87%); jaw thrust with anterior neck collar removal, 2 (4%)]. There was no significant difference in the success rate of tracheal
intubation on the first attempt between groups [Group AWS-FOB, 45 (100%); Group OVA-FOB, 44 (98%)].
Conclusions. Combined use of the paediatric blade of a Pentax Airway Scope and a fibreoptic bronchoscope enabled rapid
tracheal intubation, minimizing the use of external manoeuvres of the airway, in patients with limited mouth opening and
cervical spine immobilization by semi-rigid neck collars, compared with use of the Ovassapian airway and the fibreoptic
Clinical trial registration. NCT02827110.

Key words: airway management; bronchoscopes; laryngoscopes

Editorial decision: July 19, 2017; Accepted: July 25, 2017

C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email:

994 | Kim et al.

patients from Ajou University Hospital in Suwon, South Korea

Editor’s key points from June 2016 to December 2016. Patients with ASA physical
• Fibreoptic tracheal intubation may frequently be diffi- status class I or II, aged 20–65 yr, and undergoing robot-assisted
or laparoscopic cholecystectomy were eligible for inclusion.
cult in patients with restricted neck movement, and the
Patients with histories of cardiopulmonary, gastrointestinal, or
use of an insertion aid may facilitate intubation.
upper airway disease, increased risk of pulmonary aspiration,
• Comparison in the ease of fibreoptic tracheal intubation
BMI>30 kg m2, or poor dentition were excluded. Written in-
was made between the use of an Ovassapian oral air-
formed consent was obtained on the day before surgery. Before
way and a Pentax Airway Scope (with a blade of paedi-
induction of anaesthesia, the patients were randomly assigned
atric size) as an insertion aid.
in a 1:1 allocation ratio to one of two groups (Group OVA-FOB
• The Pentax Airway Scope (with a blade of paediatric
and Group AWS-FOB) by computer-generated codes that were
size) was more useful than the Ovassapian oral airway
maintained in sequentially numbered, sealed, opaque
in facilitating fibreoptic tracheal intubation in patients envelopes.
with restricted neck movement. All patients received standardized general anaesthesia, in-
cluding electrocardiography, non-invasive monitoring of blood
pressure, pulse oximetry, capnography, and measurement of
volatile anaesthetic concentrations. After preoxygenation with
The presence of a neck collar has been associated with de- a tight-fitting mask for 3 min, anaesthesia was induced with
creased mouth opening1 2 and worsening of direct laryngoscopic fentanyl (2 mg kg1) and thiopental sodium (4 mg kg1). After loss
view, consequently reducing the success rate of tracheal intuba- of consciousness, manual ventilation by mask was undertaken
tion.3 In such situations, fibreoptic tracheal intubation is a reli- with sevoflurane (end-tidal concentration, 2–3%) in oxygen, and
able method to obtain a high success rate of tracheal intubation rocuronium (0.6 mg kg1) was injected. Ninety seconds after
and minimize cervical spine movement.4 Under general anaes- rocuronium injection, neck circumferences, mouth opening (in-
thesia, the loss of pharyngeal muscle tone reduces the oropha- ter-incisor distance), and modified Cormack–Lehane grade by
ryngeal space for passage of the fibrescope and makes it direct laryngoscope24 were measured. After the appropriate size
difficult to maintain the fibrescope in the midline while advanc- of the semi-rigid foam neck collar (Philadelphia cervical collar)
ing its tip into the pharynx and the laryngeal inlet.5–7 Moreover, was positioned around the neck according to the manufac-
fibreoptic tracheal intubation becomes difficult when the head turer’s recommendations, the measurements of the mouth
and neck are stabilized.8 The Ovassapian airway is one of the opening and modified Cormack–Lehane grade were repeated.
specific airways designed for making the oropharyngeal space Tracheal intubation was then performed using one of the study
open and introducing the fibrescope in the midline of the oro- R
devices with a standard bevelled PortexV tracheal tube (Smiths
pharynx.9 Despite the use of this airway, partial or total obstruc- Medical, Hythe, UK; males, 8.0 mm internal diameter, 10.9 mm
tion of the fibreoptic view is frequent,10 and the active outer diameter; females, 7.0 mm internal diameter, 9.6 mm
application of a jaw thrust manoeuvre is required in patients outer diameter). A flexible fibreoptic bronchoscope (PortaViewV

with neck stabilization.9 LF-GP; Olympus Optical Company, Tokyo, Japan) with an outer
Recently, there have been several reports on the combined diameter of 4.1 mm was used. The paediatric blade of the
use of a fibrescope and a video laryngoscope.5 11–17 Among the Pentax-AWS was used. The acceptable outer diameter of the
various types of video laryngoscopes, the channel of the Pentax tracheal tube was 5.5–7.6 mm without a cuff.
Airway Scope (Pentax-AWS; Pentax Corporation, Tokyo, Japan) In all Group OVA-FOB participants, the Ovassapian airway
can be used for the passage of a fibrescope into the glottic inlet. was inserted before insertion of the flexible fibreoptic broncho-
However, as the channel was originally designed for a tracheal scope. In Group AWS-FOB, an anaesthetist inserted the paediat-
tube, an adult-sized blade is bulky for insertion; there is poor ric blade of the Pentax-AWS into the patient’s pharynx to obtain
manoeuvrability (multiple attempts) and a reported failure rate a laryngeal view on the video screen and held it in place. If ele-
of 17–30% with limited mouth opening.18–23 As a paediatric- vation of the epiglottis was easily obtained in a single advance-
sized blade is thinner, it would be easier to insert into the ment attempt, it was maintained while introducing the
mouth and have better manoeuvrability in a narrow oropharyn- fibreoptic bronchoscope. If the epiglottis could not be elevated
geal space than the adult-sized blade. Moreover, when com- in one attempt because the paediatric blade was too short, we
bined with the use of a fibrescope, the optimal position might did not attempt to elevate the epiglottis and instead introduced
be non-essential, thereby reducing the attempts for positioning. the fibreoptic bronchoscope through a tube channel of the pae-
We hypothesized that, in patients with semi-rigid foam neck diatric blade of the Pentax-AWS. In these instances, we main-
collars under general anaesthesia, the combined use of the pae- tained the position of the paediatric blade without applying a
diatric blade of the Pentax-AWS and a fibreoptic bronchoscope ventral (lifting) force to prevent impediment of the broncho-
would allow quicker tracheal intubation and require fewer ex- scope resulting from contact between the tip of the fibreoptic
ternal manoeuvres of the airway to facilitate intubation com- bronchoscope passing through the tube channel of the paediat-
pared with the use of an Ovassapian airway and the fibreoptic ric blade of the Pentax-AWS and the posterior portion of the
bronchoscope. tongue.
In both groups, if the fibreoptic view during advancement
was insufficient (i.e. not clear) or the advancement of the
Methods fibreoptic bronchoscope into the laryngeal inlet was difficult to
This study was a single-centre, prospective, open-label, ran- perform, jaw thrust was requested. If difficulty in the advance-
domized controlled superiority trial with two parallel groups. ment of the fibreoptic bronchoscope into the laryngeal inlet was
The study protocol was approved by the Institutional Review encountered even after jaw thrust, we removed the anterior
Board of Ajou University Hospital (Suwon, South Korea) and was portion of the neck collar and performed jaw thrust at once.
registered with (NCT02827110). We recruited When the tip of the fibreoptic bronchoscope was positioned
Paediatric Pentax-AWS and fibreoptic intubation | 995

above the carina, the Ovassapian airway was kept in place, significantly reduced and modified Cormack–Lehane grade
which was our routine method, and the paediatric blade of the worsened significantly after the semi-rigid neck collar was ap-
Pentax-AWS was carefully removed from the mouth to facilitate plied. There were no significant differences in patient character-
isolation from the fibreoptic bronchoscope in the channel. The istics between the groups. In Group AWS-FOB, the epiglottis was
preloaded tracheal tube was then railroaded over the fibreoptic elevated in 14 out of 45 patients.
bronchoscope. If advancement of the tracheal tube was im- The time to tracheal intubation was significantly longer in
peded during the attempt, the tracheal tube was withdrawn Group OVA-FOB patients than in Group AWS-FOB patients (me-
over the fibreoptic bronchoscope and rotated 90 anticlockwise, dian time, 50 vs 32 s; median difference, 19 s; 95% confidence in-
then re-advanced towards the trachea. After tracheal intubation terval, 14–25 s, respectively; P<0.001). In terms of the success
was accomplished, anaesthesia was maintained with sevoflur- rate of intubation, there was no significant difference between
ane (end-tidal concentration, 1.5–2.5%) in 50% oxygen in an oxy- the groups [44 (98%) vs 45 (100%)]. One patient in Group OVA-
gen–air mixture. Appropriate blood pressure and heart rate FOB was considered as a failed tracheal intubation because it
were also maintained. took 134 s to achieve tracheal intubation. A greater number of
The time to intubation was defined as the time elapsed from optimization manoeuvres were required to facilitate fibreoptic
the opening of the mouth for insertion of the Ovassapian airway tracheal intubation in Group OVA-FOB [jaw thrust, 39 (87%); jaw
or the paediatric blade of the Pentax-AWS to the removal of the thrust with anterior neck collar removal, 2 (4%)] compared with
fibreoptic bronchoscope from the mouth after confirming the the number required in Group AWS-FOB [jaw thrust, 0 (0%), jaw
placement of the tracheal tube in the trachea. Tracheal intuba- thrust with anterior neck collar removal, 1 (2%)]. The numerical
tion was considered a failure if it was not completed within rating scale for the difficulty in manipulating the fibreoptic
120 s. If tracheal intubation failed, the method of the next tra- bronchoscope for tracheal intubation was significantly higher in
cheal intubation attempt was left to the discretion of the anaes- Group OVA-FOB compared with Group AWS-FOB (5 vs 4;
thetist in charge. Mucosal damage was defined as the presence P¼0.005). There were no differences in the incidence of mucosal
of a bloodstain in the Ovassapian airway or on the paediatric damage between the two groups.
blade of the Pentax-AWS after tracheal intubation. After these
steps, the neck collar was removed. All fibreoptic intubations
were performed by a single anaesthetist (D.H.K.), who was fa-
miliar with and had been trained in intubation using a fibreoptic
bronchoscope. He determined the difficulty of the fibreoptic The combined use of the paediatric blade of the Pentax-AWS
bronchoscope manipulation on a numerical rating scale (0–10). and a fibreoptic bronchoscope rendered tracheal intubation
Manipulation of the Pentax-AWS was done by another anaes- quicker, with minimal use of external manoeuvres (jaw thrust)
thetist (Y.J.C.), who was familiar with the Pentax-AWS. of the airway compared with the use of the Ovassapian airway
The primary outcome of this study was the time to tracheal and the fibreoptic bronchoscope in individuals wearing semi-
intubation. A power analysis suggested that a minimum of 41 rigid neck collars under general anaesthesia.
patients in each group was required to demonstrate a difference In patients with a neck collar, the mouth opening was con-
in the time to tracheal intubation of 15 s with an SD of 24 s from a siderably reduced,1 limiting the oropharyngeal space21 and pre-
previous study25 to achieve 80% power at a 0.05 level of signifi- venting alignment of the oral, pharyngeal, and tracheal axes.3
cance. Considering a 10% dropout rate, the estimated total sam- These characteristics have been shown to contribute to the
ple size was 90. worsening of Cormack–Lehane grades by direct laryngoscopy,2
Statistical analysis was performed using SPSS version 21 thereby increasing the rate of failure of tracheal intubation.1 3 In
(SPSS Inc., Chicago, IL, USA). All analyses followed the the present study, mouth opening after application of the neck
intention-to-treat principle. Continuous data were tested for collar was significantly reduced and the modified Cormack–
normality of distribution using the Kolmogorov–Smirnov test. Lehane grade also decreased. Limited mouth opening and the
Data were presented as means with SD when normally distrib- oropharyngeal space can hamper the insertion of an adult-sized
uted and when Student’s t-test was used; non-normally distrib- blade of the Pentax-AWS into the mouth and cause injury to the
uted data were compared between groups using Mann–Whitney teeth and mouth, resulting in failure of tracheal intubation.22 23
U-tests and presented as medians with interquartile ranges. Moreover, it requires optimal positioning of the glottis in the
Categorical data were presented as numbers and percentages. centre of the video screen, prompting the anaesthetist to per-
The v2 or Fisher’s exact tests were used to compare the categori- form scooping movements, consequently resulting in multiple
cal variables between the groups. P-values <0.05 were consid- attempts.18 20 21 23 The thickness of the standard adult blade of a
ered statistically significant. The difference between groups for Pentax-AWS is 18 mm, requiring an inter-incisor gap of 25 mm
the primary outcome measure is reported with the 95% confi- for smooth manipulation of the blade.26 27 A paediatric-sized
dence interval. blade is the thinnest among the Pentax-AWS blades, and thus it
would allow for easier insertion into the mouth and better
manoeuvrability in a narrow oropharyngeal space than the
adult-sized blade. Moreover, when used in combination with a
Results fibrescope, optimal positioning might become non-essential,
Ninety-nine patients were screened for the study. Seven pa- thereby reducing attempts for positioning. Given that easy in-
tients declined to participate. Two patients were excluded be- sertion and fewer scooping movements are desirable in patients
cause of poor dentition. The participant flow diagram for the with potential cervical spine injury, the paediatric blade of the
study is presented in Figure 1. A total of 90 patients were en- Pentax-AWS was chosen to overcome these difficulties. In prac-
rolled, and all patients completed the study. There were no tice, it was easy to insert and position the tip of the paediatric
missing data in the analysis. The patient characteristics and air- blade of the Pentax-AWS into the pharynx. Moreover, the scoop-
way assessment data before and after the application of a semi- ing movement for the advancement of the paediatric blade was
rigid neck collar are shown in Table 1. Mouth opening was confined to one attempt, and fibreoptic tracheal intubation was
996 | Kim et al.

Enrollment Assessed for eligibility (n = 99)

Excluded (n=9)
Not meeting inclusion crtieria (n = 2)
Declined to participate (n =7)
Other reaons (n =0)

Randomized (n=90)

Allocated to a control group (n= 45) Allocated to a block group (n = 45)
Received allocated intervention (n=45) Received allocated intervention (n =45)
Did not receive allocated intervention (n= 0) Did not receive allocated intervention (n = 0)


Lost to follow-up (n = 0) Lost to follow-up (n =0)


Analysed (n=45) Analysed (n = 45)

Excluded from analysis (n= 0) Excluded from analysis (n = 0)

Fig 1 CONSORT flow diagram of recruitment and assessment of study participants.

feasible regardless of whether the epiglottis was elevated. There various conditions, such as the level of emergency, patient co-
was some concern that the shorter paediatric blade might im- operation, feasibility of mask ventilation, or the provider’s fa-
pinge on the posterior third of the tongue and force the tongue miliarity and experience with the procedure.28 29 One problem
backwards towards the oropharynx, thereby impeding the bron- with fibreoptic orotracheal intubation under general anaesthe-
choscopy, but there were no such issues when the paediatric sia is that the loss of pharyngeal muscle tone reduces the oro-
blade of the Pentax-AWS was used. The combined use of the pharyngeal space for the passage of the fibreoptic bronchoscope
paediatric blade of the Pentax-AWS and a fibreoptic broncho- and makes it difficult to maintain the fibreoptic bronchoscope
scope was a feasible option in patients with limited mouth in the midline while advancing its tip into the pharynx and the
opening. laryngeal inlet.5–7 Consequently, specific oral airway or addi-
In patients wearing neck collars because of potential cervical tional manoeuvres to open the pharyngeal airway are com-
spine injuries, an alternative method is required instead of con- monly required.7 9 In the present study, while applying the
ventional direct laryngoscopy.3 The optimal method for guaran- Ovassapian airway, the fibreoptic view was frequently ob-
teeing a high success rate of intubation while minimizing structed and identification of the midline was difficult. Only
cervical spine movement remains under debate.1 In addition to when jaw thrust was applied in 91% of the patients of Group
being a reliable method, fibreoptic tracheal intubation might be OVA-FOB was a laryngeal view obtained. On the contrary, in all
a good alternative for minimizing cervical spine movements.4 patients of Group AWS-FOB, the midline was easily identified
Although awake fibreoptic tracheal intubation is the most reli- because the epiglottis or laryngeal inlet was obtained on the
able method, fibreoptic tracheal intubation can also be per- screen of the Pentax-AWS without additional manoeuvres (e.g.
formed under general anaesthesia upon consideration of jaw thrust), and the gel-coated fibreoptic bronchoscope could be
Paediatric Pentax-AWS and fibreoptic intubation | 997

scale, which scored difficulty in manipulating the fibreoptic

Table 1 Patient characteristics and airway assessment. Data bronchoscope for tracheal intubation, the combined use of the
are represented as the mean (SD) or number. C-L grade, modi-
two devices was also significantly easier than the method used
fied Cormack–Lehane grade; Group AWS-FOB, tracheal intuba-
tion with the paediatric blade of the Pentax-AWS and the in Group OVA-FOB. Therefore, the combined use of the paediat-
fibreoptic bronchoscope; Group OVA-FOB, tracheal intubation ric blade of the Pentax-AWS and a fibreoptic bronchoscope
with Ovassapian airway and the fibreoptic bronchoscope could be a very useful alternative method, allowing quicker and
easier fibreoptic tracheal intubation in patients with neck
Group Group collars.
OVA-FOB AWS-FOB When a neck collar is applied, neck flexion, extension, and
(n¼45) (n¼45) rotation are possible to some extent,30 31 even with the use of
manoeuvres to limit neck movement. The fibreoptic broncho-
Age (yr; median [range]) 43 [29–57] 42 [25–60]
scope is suitable for minimizing cervical movements; however,
Sex (male/female) 20/25 20/25
the present study emphasizes how essential jaw thrust is dur-
Weight (kg) 66 (11) 65(11)
Height (cm) 165 (9) 165 (8)
ing fibreoptic tracheal intubation in patients with neck collars.
ASA grade (I/II) 40/5 43/2 Although the effect of jaw thrust on movement of the cervical
Neck circumference (cm) 38 (4) 38 (4) spine has been reported to be better than head tilt–chin lift in
Mouth opening (cm) patients with neck collars,32 it was not easy to apply the jaw
Before neck collar 4.0 (3.3) 3.8 (0.7) thrust efficiently without lifting the chin. The Pentax-AWS has
After neck collar 2.4 (0.3) 2.5 (0.4) been reported to produce less cervical spine movement.33
C-L grade (I/IIa/IIb/III/IV) by direct laryngoscope Moreover, in the present study, we also demonstrated that the
Before neck collar 18/12/14/1/0 21/13/11/0/0 ventral force of the Pentax-AWS was unnecessary, which might
After neck collar 3/4/23/15/0 3/12/22/8/0 make the tip of the fibreoptic bronchoscope passing through the
tube channel of the paediatric blade of the Pentax-AWS contact
the posterior portion of the tongue, thereby intruding on the ad-
vancement of the fibreoptic bronchoscope. We conclude that
the advancement alone of the paediatric blade of the Pentax-
AWS into the patient’s pharynx without a ventral (lifting) force
Table 2 Airway management data. Data are represented as the
median (interquartile range) or number (percentage). The time
could limit the movement of the cervical spine, although cervi-
to tracheal intubation and NRS difficulty score were compared cal movements were not measured in the present study.
using a Mann–Whitney U-test. Group AWS-FOB, tracheal intu- As a conduit for fibreoptic tracheal intubation in patients
bation with the paediatric blade of the Pentax-AWS and the with limited neck movement, a laryngeal mask airway has also
fibreoptic bronchoscope; Group OVA-FOB, tracheal intubation been reported to be useful.8 34 35 It can be inserted without mov-
with Ovassapian airway and the fibreoptic bronchoscope; NRS
ing the cervical spine, and the use of a fibrescope through a la-
difficulty score, difficulty of fibreoptic bronchoscope manipula-
tion as a numerical rating scale
ryngeal mask airway is associated with an excellent success
rate for tracheal intubation.36 37 In addition, unlike the paediat-
Group Group P-value ric blade of Pentax-AWS, it allows for ventilation to continue
OVA-FOB AWS-FOB while attempting to intubate the trachea with a fibrescope. Its
(n¼45) (n¼45) limitations include a limited tracheal tube size and difficulty
with the removal of the laryngeal mask airway leading to an in-
Time to tracheal intubation (s) 50 (43–63) 32 (24–43) <0.001 advertent extubation.38 In contrast, the removal of the paediat-
Success rate on the first 44 (98) 45 (100) 1.000 ric blade of the Pentax-AWS after the insertion of a fibrescope
attempt into the trachea was easy, and an adult-sized tracheal tube
Jaw thrust <0.001 could be advanced over the fibreoptic bronchoscope.
No use 4 (9) 44 (98)
This study had several limitations. First, there was a poten-
Use under neck collar 39 (87) 0 (0.0)
tial bias because the anaesthetists could not be blinded to the
Use after removal of 2 (4) 1 (2)
group allocation. Second, the fibreoptic bronchoscope procedure
neck collar
was performed by only one experienced anaesthetist; therefore,
Mucosal damage 4 (9) 3 (7) 1.000
the assessment of the difficulty score reflected only one per-
NRS difficulty score 5 (4–6) 4 (3–5) 0.005
son’s judgement. This finding might therefore not be translat-
able to less experienced users. However, we believe that the use
of the paediatric blade of the Pentax-AWS for passing of the
fibreoptic bronchoscope would be easy even for less experi-
kept straight within the channel and passed smoothly through enced users. Third, the patients in this study were healthy pa-
the tube channel of the paediatric blade of the Pentax-AWS. tients in whom the neck collar simulated a difficult airway. This
Especially in patients where the epiglottis was elevated on the scenario is different from clinical practice, in which the pa-
screen, the advancement of the fibreoptic bronchoscope into tient’s airways might be oedematous, modified, or not clear be-
the trachea was so easy that even users with less experience cause secretions of blood or sputum. Fourth, the combined
and training could perform the procedure. In patients where the method used in this study requires two operators.
anterior wall of the epiglottis was visible on the screen, the la- In conclusion, the combined use of the paediatric blade of
ryngeal inlet was visible on the eyepiece of the fibreoptic bron- the Pentax-AWS and a fibreoptic bronchoscope enables rapid
choscope when the tip of the bronchoscope was manipulated in intubation while minimizing the use of external manoeuvres in
an upward (anterior) direction after passing between the epi- patients with limited mouth opening and cervical spine immo-
glottis and pharyngeal wall, and advancement of the fibreoptic bilization by a semi-rigid neck collar, compared with the
bronchoscope was possible. According to the numerical rating Ovassapian airway and fibreoptic bronchoscope.
998 | Kim et al.

Authors’ contributions patients with a suspected difficult airway undergoing elective

uvulopalatopharyngoplasty. Ains-Shams J Anaesthesiol 2015; 8:
Study design/planning: Y.J.C., D.H.K., J.Y.Y. 308
Study conduct: Y.J.C., D.H.K., S.Y.H. 15. Nishikawa K, Hukuoka E, Kawagishi T, Shimodate Y,
Data analysis: J.Y.Y., S.Y.H. R V
Yamakage M. Efficacy of the Airtraq laryngoscope with a
Writing the manuscript: D.H.K., Y.J.C. fiberoptic bronchoscope compared with that of AirtraqV

Revising the manuscript: D.H.K., J.Y.Y., S.Y.H., Y.J.C.. alone for tracheal intubation: a manikin study. J Anesth 2011;
25: 93–7
16. Sharma D, Kim LJ, Ghodke B. Successful airway management
Declaration of interest R
with combined use of GlidescopeV videolaryngoscope and
None declared. fiberoptic bronchoscope in a patient with Cowden syn-
drome. Anesthesiology 2010; 113: 253–5
17. Zhang S, Yi M. AirtraqV laryngoscope-assisted fiberoptic
Funding bronchoscope intubation in a child with Pierre-Robin se-
This research received no specific grants from any funding quence: a case report. Int J Clin Exp Med 2015; 8: 6372–3
agencies in the public, commercial, or not-for-profit sectors. 18. Kim JK, Kim JA, Kim CS, Ahn HJ, Yang MK, Choi SJ.
Comparison of tracheal intubation with the Airway Scope or
Clarus Video System in patients with cervical collars.
References Anaesthesia 2011; 66: 694–8
1. Goutcher CM, Lochhead V. Reduction in mouth opening with 19. Aoi Y, Inagawa G, Nakamura K, Sato H, Kariya T, Goto T.
semi-rigid cervical collars. Br J Anaesth 2005; 95: 344–8 Airway Scope versus Macintosh laryngoscope in patients
2. Heath KJ. The effect of laryngoscopy of different cervical with simulated limitation of neck movements. J Trauma
spine immobilisation techniques. Anaesthesia 1994; 49: 843–5 2010; 69: 838–42
3. Suppan L, Tramèr MR, Niquille M, Grosgurin O, Marti C. 20. Komatsu R, Kamata K, Hoshi I, Sessler DI, Ozaki M. Airway
Alternative intubation techniques vs Macintosh laryngos- Scope and gum elastic bougie with Macintosh laryngoscope
copy in patients with cervical spine immobilization: system- for tracheal intubation in patients with simulated restricted
atic review and meta-analysis of randomized controlled neck mobility. Br J Anaesth 2008; 101: 863–9
trials. Br J Anaesth 2016; 116: 27–36 21. Komatsu R, Kamata K, Sessler DI, Ozaki MA. Comparison of
4. Fuchs G, Schwarz G, Baumgartner A, Kaltenbock F, Voit- the Airway Scope and McCoy laryngoscope in patients with
Augustin H, Planinz W. Fiberoptic intubation in 327 neuro- simulated restricted neck mobility. Anaesthesia 2010; 65:
surgical patients with lesions of the cervical spine. 564–8
J Neurosurg Anesthesiol 1999; 11: 11–6 22. Kim JW, Lee KR, Hong DY, Baek KJ, Lee YH, Park SO. Efficacy
5. Greib N, Stojeba N, Dow WA, Henderson J, Diemunsch PA. A of various types of laryngoscope (direct, Pentax Airway
combined rigid videolaryngoscopy-flexible fibrescopy intu- Scope and GlideScope) for endotracheal intubation in vari-
bation technique under general anesthesia. Can J Anaesth ous cervical immobilisation scenarios: a randomised cross-
2007; 54: 492–3 over simulation study. BMJ Open 2016; 6: e011089
6. Hagberg CA, Artime CA, Daily WH, eds. The Difficult Airway: a 23. Aoi Y, Inagawa G, Hashimoto K, et al. Airway Scope laryngos-
Practical Guide. Oxford: Oxford University Press, 2013 copy under manual inline stabilization and cervical collar
7. Morris IR. Fibreoptic intubation. Can J Anaesth 1994; 41: immobilization: a crossover in vivo cinefluoroscopic study.
996–1007; discussion 1007–8 J Trauma 2011; 71: 32–6
8. Asai T, Eguchi Y, Murao K, Niitsu T, Shingu K. Intubating la- 24. Yentis SM, Lee DJ. Evaluation of an improved scoring system
ryngeal mask for fibreoptic intubation - particularly useful for the grading of direct laryngoscopy. Anaesthesia 1998; 53:
during neck stabilization. Can J Anaesth 2000; 47: 843–8 1041–4
9. Aoyama K, Seto A, Takenaka I. Simple modification of the 25. Cole AF, Mallon JS, Rolbin SH, Ananthanarayan C. Fiberoptic
Ovassapian fiberoptic intubating airway. Anesthesiology 1999; intubation using anesthetized, paralyzed, apneic patients.
91: 897 Results of a resident training program. Anesthesiology 1996;
10. Greenland K, Lam M, Irwin M. Comparison of the Williams 84: 1101–6
airway intubator and Ovassapian Fibreoptic Intubating 26. Hirabayashi Y, Seo N. Airway Scope: early clinical experience
Airway for fibreoptic orotracheal intubation. Anaesthesia in 405 patients. J Anesth 2008; 22: 81–5
2004; 59: 173–6 27. Thong SY, Lim Y. Video and optic laryngoscopy assisted tra-
11. Ara T, Mori G, Adachi E, Asai T, Okuda Y. Combined use of cheal intubation – the new era. Anaesth Intensive Care 2009;
the GlideScope and fiberoptic bronchoscope for tracheal in- 37: 219–33
tubation in a patient with difficult airway. Masui 2014; 63: 28. Austin N, Krishnamoorthy V, Dagal A. Airway management
647–9 in cervical spine injury. Int J Crit Illn Inj Sci 2014; 4: 50–6
12. Choi GS, Park SI, Lee EH, Yoon SH. Awake GlidescopeV intu- 29. Koerner IP, Brambrink AM. Fiberoptic techniques. Best Pract
bation in a patient with a huge and fixed supraglottic mass - Res Clin Anaesthesiol 2005; 19: 611–21
A case report-. Korean J Anesthesiol 2010; 59: S26–9 30. Benger J, Blackham J. Why do we put cervical collars on con-
13. El-Tahan MR, Doyle DJ, Khidr AM, Regal MA, El Morsy AB, El scious trauma patients? Scand J Trauma Resusc Emerg Med
Mahdy M. Awake tracheal intubation with combined use of 2009; 17: 44
King VisionTM videolaryngoscope and a fiberoptic broncho- 31. James CY, Riemann BL, Munkasy BA, Joyner AB. Comparison
scope in a patient with giant lymphocele. Middle East J of cervical spine motion during application among 4 rigid
Anaesthesiol 2014; 22: 609–12 immobilization collars. J Athl Train 2004; 39: 138–45
14. Maghawry KM, Rayan AA. Tracheal intubation with the aid of 32. Prasarn ML, Horodyski M, Scott NE, Konopka G, Conrad B,
fiberoptic bronchoscopy with or without the C-MAC device in Rechtine GR. Motion generated in the unstable upper
Paediatric Pentax-AWS and fibreoptic intubation | 999

cervical spine during head tilt–chin lift and jaw thrust ma- 35. Asai T. Fiberoptic tracheal intubation through the laryngeal
neuvers. Spine J 2014; 14: 609–14 mask in an awake patient with cervical spine injury. Anesth
33. Maruyama K, Yamada T, Kawakami R, Kamata T, Yokochi M, Analg 1993; 77: 404
Hara K. Upper cervical spine movement during intubation: 36. Lee JJ, Lim BG, Lee MK, Kong MH, Kim KJ, Lee JY. Fiberoptic in-
fluoroscopic comparison of the AirWay Scope, McCoy laryn- tubation through a laryngeal mask airway as a management
goscope, and Macintosh laryngoscope. Br J Anaesth 2008; 100: of difficult airway due to the fusion of the entire cervical spine
120–4 -A report of two cases-. Korean J Anesthesiol 2012; 62: 272–6
34. Mathew DG, Ramachandran R, Rewari V, Trikha A. 37. Campo SL, Denman WT. The laryngeal mask airway: its role
Endotracheal intubation with Intubating Laryngeal Mask in the difficult airway. Int Anesthesiol Clin 2000; 38: 29–45
Airway (ILMA)TM, C-TrachTM, and Cobra PLATM in simulated 38. Alberts AN. The LMA Classic as a conduit for tracheal intuba-
cervical spine injury patients: a comparative study. J Anesth tion in adult patients: a review and practical guide. South Afr
2014; 28: 655–61 J Anaesth Analg 2014; 20: 77–88

Handling editor: Tak Asai