Borescope Vs Laryngoscope in Difficult Airway Management by Non-Expert Personnel: A Non-Randomized Pilot Study in a Simulated Environment
Valentina Franco Uribe1*, Duván Andrés Vélez Ríos2, Laura Chavarriaga Jiménez3, Juan Diego
Pulecio3, Andrés Felipe Prado Reina4, Juan Camilo Gómez Salgado5, and Mauricio Calderón Marulanda5
1Anesthesiology Resident, CES University, Colombia
2Medical Student, University of Caldas, Colombia
3Medical Doctor, University of Caldas, Colombia
4General Surgery Resident, Military University Nueva Granada, Colombia
5Anesthesiologist, University of Caldas, Colombia
Valentina Franco Uribe, Anesthesiology
Program, CES University, Cl. 10a #22 - 04, Medellin, Antioquia, Colombia, Tel: 573206321211; Email: email@example.com
Submitted: 07 February 2019; Accepted: 17 April 2019; Published: 19 April 2019
Cite this article:
Uribe VF, Vélez Ríos DA, Jiménez LC, Pulecio JD, Prado Reina AF, et al. (2019) Borescope Vs Laryngoscope in Difficult Airway Management
by Non-Expert Personnel: A Non-Randomized Pilot Study in a Simulated Environment. Int J Clin Anesthesiol 1: 4.
Introduction: Though direct laryngoscopy is the method of choice to secure the airway, it has multiple disadvantages. There are
different devices to improve the visualization of the airway, but their high cost and need for advanced training limit their use. Borescope
would be a cost-effective option with advantages similar to those types of devices.
Objective: The primary objective was to compare successful intubation at first attempt with and without the use of borescope. The
secondary objective was to compare the average total intubation time with and without the use of borescope.
Materials and methods: Controlled non-randomized pilot study in a simulated environment. Population frame work of 48 medical
students who received training on the basic management of the device. A difficult airway was recreated in a simulation laboratory using
the Laerdal Airway Management Trainer model and intubation parameters were compared using a conventional laryngoscope under direct
vision and through borescope.
Results: In the group with borescope, 22 out of the 24 participants performed the intubation at the first attempt (91.6%) while in the
group without borescope, 15 participants performed the intubation at the first attempt (62.5%) (P: 0.02). No statistically significant difference
was found in any other evaluated variable.
Conclusion: Borescope could be an effective and economic alternative compared to other devices, since it has similar or better
success rates, even for non-expert personnel.
Keywords: Airway management; Intratracheal intubation; Equipment and supplies
Among the main competences that a general practitioner
should have, those related to adequately securing the airway
stand out. Failure in achieving adequate airway patency in
a patient with difficult airway (DA) may compromise his
ventilation and oxygenation. The incidence of DA in surgical
population depends on the degree of difficulty; it may range from 1 to 18% in patients who require several intubation attempts .
Its incidence in general population varies between 1.15 and 3.8%
and failed intubation between 0.13 and 0.3%, which may result
in complications as serious as bronchoaspiration, upper airway
lesions, cerebral hypoxia, and death .
Direct laryngoscopy is the method of choice to ensure the
airway in both elective and urgent cases. However, multiple
disadvantages are observed along this procedure, e.g., difficulty
in obtaining optimal glottic visualization or greater cervical spine
movement. In the market there are several devices useful to
minimize risks, which promise to improve the results and reduce
complications. Video laryngoscopes are one of the most used
because they obtain higher success rates, but their high cost and
the need for a greater learning curve for some of them are the
main difficulties that limit their use .
In this study, a device known as borescope, an optical fiber
that allows the visualization of difficult access paths was used.
At one end, it has a camera with LED light and, at the other end,
an USB connector through which the image is transmitted in
real time to a cellular device , by means of an Android or IOS
This pilot test was conducted from September 2017 to March
2018. A call was sent to the medical students of the University
of Caldas. To be included the students must have taken and
passed the subject ‘anesthesiology and resuscitation’ in the year
immediately prior to the study, to be enrolled in the Medicine
program, as established in the official curriculum of the University
of Caldas. The students were divided into two groups, and they
were assigned an odd or even number according to the order of
arrival. All participants received instructions on the incorporation
of the borescope into the laryngoscope, its basic function and the
procedure to be performed. Data collection was carried out in
the University’s clinical simulation laboratory using the Laerdal
Airway Management Trainer (Laerdal, Stavanger, Norway) for
intubation, where a DA was recreated by means of a cervical
collar ensuring a Cormack-Lehane III. The USB / borescope
device and the Android V3.1 or higher operating system was
used, it allowed the USB host on-the-go (OTG) function, through
which an interface was established between the device’s camera
and the mobile phone to get the image in real time. Cell phones
were not specific, however, they all met the criteria requested by
the manufacturer of the device, especially, a resolution greater
than 640x480 (p/p). In order to properly use the borescope,
the “CameraFi” application (Vault Micro Inc., Seoul, Korea) was
downloaded for free to each device from the Google Play store (Figure 1).
The borescope camera was fixed 35 mm from the tip on the
base of the Macintosh sheet number 3 with clean adhesive tape
(strapper) and its stability was verified; this spot was determined
considering that the purpose was to achieve the best visualization
with as much anatomical information as possible without missing
details in the quality of the image. Each participant performed
intubation with orotracheal tube 7.5, with balloon and guide.
Once the participant was ready, the timer was set to zero and
immediately started when the student took the laryngoscope; the
stopwatch was stopped once intubation was declared or after a
failure. The intubation of the manikin was verified by insufflation
with self-inflating bag (Figures 2 and 3).
The primary objective was to compare successful intubation
at first attempt with and without the use of borescope. The
secondary objective was to compare the average total intubation
time until with and without the use of borescope. Evaluated
variables: failed intubation, i.e., the impossibility to achieve
successful intubation after 120 seconds or after 3 unsuccessful
attempts, failed attempt, i.e., when the participant removed the
tube from the manikin’s mouth or when esophageal intubation
was performed. The number of attempts required by each
participant, the total intubation time and whether or not there
was esophageal intubation were also evaluated. In addition, 2
subjective variables were recorded: procedure performance
difficulty and visualization of vocal cords. The information was
collected manually by the research participants and later analyzed
with the statistical program Stata version 12. Contingency tables
were made, chi test2 and Fisher’s exact tests when there were
cells with five cases or less and Student’s t-test for continuous
variables with normal distribution.
The inclusion criteria stated in this study were met by 48
students; all the participants were included in the final analysis.
There were 2 failed intubation cases in the group without
borescope (8.3%) and one case in the group with borescope
(4.2%). However, this difference is not statistically significant (P:
0.5). In the group with borescope, 22 out of the 24 participants
performed the intubation at the first attempt (91.6%), compared
with 15, out of 24 (62.5%), in the group without borescope (P:
0.02). The variable number of attempts is also affected by the use of borescope since most participants who used it required
one attempt to achieve successful intubation, while a greater
proportion of participants who did not use borescope required
more attempts (Table 1).
No statistically significant differences were found in the
average total intubation time (40.09 ± 5.85 in the group without
borescope and 45.42 ± 6.39 in the group with borescope; Student
t-test P: 0.5). Although a trend towards greater number of
esophageal intubation was found (2 cases in the group without
borescope (8.3%) and none in the group with borescope), it
was not statistically significant (P: 0.2). Similarly, no differences
were found in the number of students who reported difficulty
during the procedure (29.2% without borescope and 37.5% with
borescope, P: 0.3). However, a higher proportion of students who
used borescope reported having visualized the glottis (87.5%),
compared with the group without borescope (62.5%), P: 0.04.
This pilot test confirmed that borescope could be an
effective alternative to improve the success rate of orotracheal
intubation at the first attempt, even in non-expert personnel. A
2016 Cochrane systematic review included 64 studies with 7044
adult participants and compared the use of video laryngoscope
(VL) of one or more designs with a Macintosh laryngoscope .
The authors concluded that VL may reduce the number of failed
intubations, particularly among patients who have a difficult
airway, improve glottic vision and decrease laryngeal trauma.
There is no difference in patients with airway defined as normal
or without predictors of difficult airway; this due to the great
heterogeneity in the results dealing with time, attempts and
failures in intubation. This is why the borescope model recreating
a DA was used; the main finding was that, with the device, the rate
of successful intubations in the first attempt (91.6%) increases
significantly with respect to the exclusive use of laryngoscope (62.5%).
The first attempt to manage a borescope is not easy for
students; it requires a greater learning curve. However, due to
the number of successful intubations at the first attempt and the
greater visualization of the glottis, it could be easily handled by
non-expert personnel. Borescope use may be a part of training
and teaching in medical students, by clinical simulation in
different scenarios to improve psychomotor skills and abilities in
anesthesia practice , mainly in airway management.
There is a growing implementation of technology in the
practice of anesthesiology and related areas. Sheraton et al. ,
described the use of smart phones for development in the world of
anesthesia and the success they will have in clinical practice. The different applications in smart phones are available for free, like
the application used in this study, which guarantees easy access
for borescope use, thus, success is expected. Low D and Groos
 used an IOS device to assist nasal fiber optic intubation in a
simulation model and improved intubation times in all attempts.
These findings are important since they give rise to different
management alternatives in different areas of anesthesiology
and resuscitation in a world that technologically advances very
fast; they also open the way to other works of research about
borescope, and not exclusively in airway management.
We found very few studies about the use of this device
in humans. Ahmad Sabry et al. , used borescope for nasal
intubation and concluded that it would be an economical
alternative to a fibrolaryngoscope since they used it with 8
patients without any complications. Karippacheril et al. ,
reported their initial experience with the device in 24 patients
older than 16 years taken to elective surgery; these researchers
intubated 22 patients at the first attempt, and the other 2 required
2 attempts, none of them had associated complications. The
authors concluded that this is a personal and economic device
and that it is safe and reliable for clinical use.
Additionally, Chaparro et al. , conducted a non-systematic
review to show the current state of videolaryngoscopes and
their impact on airway management. The authors argue that the
visualization of the larynx through devices such as VL does not
guarantee the success of intubation, that the effectiveness of VL in
AD has limited evidence and that the success of intubation with VL
is related to experience in its management, with a learning curve
that does not exceed 10 patients. Finally, the authors conclude
that there are still controversies in the management of AD and
the safety it represents for patients. Considering these aspects, it
is important to conduct future research regarding the limitations
that borescope could have both in airway management and in its
safety, which will require different studies despite the fact that it
has been shown to be safe in humans.
It would be necessary to conduct controlled clinical trials
in simulation scenarios and later with actual patients in order
to compare the use of borescope with other devices, such as
videolaryngoscopy and standard laryngoscope.
Although borescope is a new device and it has not been
proven as a clinical tool in airway management, it could work as
an effective and cheaper alternative to other devices with similar
or even better successful rates.
Dr. Fernando Arango, for his collaboration in the design and
analysis of this study
The funds used for this pilot study were provided by the
researchers. No financial assistance was received from any
other institution and / or person outside of it. The University
of Caldas provided the clinical simulation laboratory where the model Laerdal Airway Management Trainer (Laerdal, Stavanger,
Norway) was used for intubation, and other equipment. There
were 4 borescopes which were acquired with the researchers’
own resources for an approximate price of 10 US dollars each.
Very few studies that could serve as a reference have used
borescope as a clinical tool in patients as well as in simulation
scenarios. This pilot test is limited because the students were not
assigned randomly to the use of the borescope and also due to
small sample size given the difficulty of finding students that met
the inclusion criteria.