INTRODUCTION: Flexible bronchoscopy is the gold standard for difficult airway management. Clinicians are using videolaryngoscopy increasingly because it is perceived to be easier to use with high success rates. We conducted this study to compare the success rates of the two techniques when used after failed direct laryngoscopy in children with difficult tracheal intubations. METHODS: We identified cases where initial attempts at direct laryngoscopy failed in the multicentre Pediatric Difficult Intubation Registry from August 2012-September 2023. After propensity score matching, we compared success rates and complications when videolaryngoscopy and flexible bronchoscopy were used as rescue techniques in the matched cohort and in matched patients weighing <
5 kg. RESULTS: Clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy when direct laryngoscopy failed (64.7%, 1426/2281 vs. 7.3%, 156/2281, p <
0.001). Propensity score matched cohorts did not differ with respect to first-attempt success, eventual success and complications. For the subgroup of infants <
5 kg, clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy to rescue failed direct laryngoscopy (54.3%, 295/543 vs. 8.9%, 44/543, p <
0.001). First-attempt success was 43% (62/145) with videolaryngoscopy and 62% (18/29) with flexible bronchoscopy (odds ratio 2.19, 95%CI 0.96-4.98, p = 0.061). Eventual success was 71% (103/145) with videolaryngoscopy and 90% (26/29) with flexible bronchoscopy (odds ratio 3.53, 95%CI 1.03-12.2, p = 0.046). Complications did not differ between the techniques. DISCUSSION: Videolaryngoscopy was chosen more frequently than flexible bronchoscopy as a rescue technique in a cohort of children with difficult direct laryngoscopy, with similar success and complication rates. For small infants, flexible bronchoscopy had a higher eventual success rate, underscoring the importance of maintaining proficiency with flexible bronchoscopy.