Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials.
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ABSTRACT: There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients.We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes.Twelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P?=?0.28; low-quality evidence). There was significant heterogeneity among studies (I 2?=?91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P??0.05), although a slightly higher overall success rate was shown (RR, 1.11; P?=?0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P?>?0.05), except for a lower rate of esophageal intubation (P?=?0.01) and a higher rate of Cormack and Lehane grade 1 (P?CONCLUSIONSOn the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators.
Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials.
<h4>Background</h4>There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients.<h4>Methods</h4>We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only ra ...[more]
Project description:BackgroundNasotracheal intubation (NTI) is commonly performed in oromaxillofacial surgeries. We did this metanalysis to ascertain whether use of video laryngoscopy (VL) provided better NTI characteristics as compared to direct laryngoscopy (DL) in patients undergoing oromaxillofacial surgeries.MethodsWe performed a systematic search to identify randomized controlled trials comparing VL with DL for NTI in adults undergoing elective oromaxillofacial surgery. The primary outcome was time to intubation. Secondary outcomes included the first attempt success, overall success, incidence of nasal bleeding, Cormack and Lehane grade, and maneuvers required.ResultsOf the 456 studies identified following a systematic search, 10 were included. Meta-analysis showed a significantly lower time to tracheal intubation favoring VL (mean difference: -9.04, 95% CI [-12.71, -5.36], P < 0.001; I2 = 59%). VL was also associated with a greater first attempt success (relative risk [RR]: 1.10, 95% CI [1.04, 1.16], P = 0.001). Maneuvers to facilitate intubation were less with VL (RR: 0.22, 95% CI [0.10, 0.51], P < 0.001). There was no difference in overall intubation success (RR: 1.04, 95% CI [0.98, 1.10], P = 0.17). The incidence of bleeding did not differ between the DL and VL groups (RR: 0.59, 95% CI [0.32, 1.08], P = 0.09).ConclusionsEvidence as per this meta-analysis suggests VL leads to a shorter time to NTI, a greater first attempt success rate, and reduced need for maneuvers when compared to DL. The present study supports use of VL as a first line device for NTI in oral-maxillofacial surgeries in experienced hands.
Project description:BackgroundTracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative.MethodsWe conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider's level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy.ResultsFPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers' expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified.ConclusionAirway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.
Project description:OBJECTIVE:Video laryngoscopes are used for managing difficult airways. This study compared three video laryngoscopes' (Pentax-Airway Scope [Pentax], King Vision[King] and McGrath MAC [McGrath]) performances with the Macintosh direct laryngoscope (Macintosh) as emergency tracheal intubations (TIs) reference. DESIGN:Retrospective cohort study. SETTING:The emergency department (ED) and the intensive care unit (ICU) of two Japanese tertiary-level hospitals. PARTICIPANTS:All consecutive video-recorded emergency TI cases in EDs and ICUs between December 2013 and June 2015. PRIMARY OUTCOME MEASURES:The primary study endpoint was first-pass intubation success. A subgroup analysis examined the first-pass intubation success of expert versus non-expert operators. A logistic regression analysis was performed to identify the predictors of first-pass intubation success. RESULTS:A total of 287 emergency TIs were included. The first-pass intubation success rates were 78%, 58%, 78% and 58% for the Pentax, King, McGrath and Macintosh instruments, respectively (p=0.004, Fisher's exact test). The non-expert operators' success rates were significantly higher (p=0.00004, Fisher's exact test) for the Pentax (87%) and McGrath (78%) instruments than that for the King (50%) and Macintosh (46%) instruments, unlike that of the experts (67%, 67%, 78% and 78% for Pentax, McGrath, King and Macintosh, respectively; p=0.556, Fisher's exact test). After TI indication, difficult airway characteristics, and expert versus non-expert operator parameters adjustments, the Pentax (OR=3.422, 95% CI 1.551 to 7.550; p=0.002) and McGrath (OR= 3.758, CI 1.640 to 8.612; p=0.002) instruments showed significantly higher first-pass intubation success odds when compared with the Macintosh laryngoscope (reference, OR=1). The King instrument, however, (OR=1.056; 95% CI 0.487 to 2.289, p=0.889) failed to show any significant superiority. CONCLUSION:The Pentax and McGrath laryngoscopes showed significantly higher emergency TI first-pass intubation success rates than the King laryngoscope when compared with the Macintosh laryngoscope, especially for non-expert operators. TRIAL REGISTRATION NUMBER:UMIN000027925; Results.
Project description:Recent trials showed that video laryngoscopy (VL) did not yield higher first-attempt tracheal intubation success rate than direct laryngoscopy (DL) and was associated with higher rates of complications. Tracheal intubation can be more challenging in the general ward than in the intensive care unit. This study aimed to investigate which laryngoscopy mode is associated with higher first-attempt intubation success in a general ward.This is a retrospective study of tracheal intubations conducted at a tertiary academic hospital. This analysis included all intubations performed by the medical emergency team in the general ward during a 48-month period.For the 958 included patients, the initial laryngoscopy mode was video laryngoscopy in 493 (52%) and direct laryngoscopy in 465 patients (48%). The overall first-attempt success rate was 69% (664 patients). The first-attempt success rate was higher with VL (79%; 391/493) than with DL (59%; 273/465, p?<?0.001). The first-attempt intubation success rate was higher among experienced operators (83%; 266/319) than among inexperienced operators (62%; 398/639, p?<?0.001). In multivariate logistic regression analyses, VL, pre-intubation heart rate, pre-intubation SpO2?>?80%, a non-predicted difficult airway, experienced operator, and Cormack-Lehane grade were associated with first-attempt intubation success in the general ward. Over all intubation-related complications were not different between two groups (27% for VL vs. 25% for DL). However, incidence of a post-intubation SpO2?<?80% was higher with VL than with DL (4% vs. 1%, p?=?0.005), and in-hospital mortality was also higher (53.8% vs. 43%, p?=?0.001).In a general ward setting, the first-attempt intubation success rate was higher with video laryngoscopy than with direct laryngoscopy. However, video laryngoscopy did not reduce intubation-related complications. Furthers trials on best way to perform intubation in the emergency settings are required.
Project description:The available meta-analyses have inconclusively indicated the advantages of video-laryngoscopy (VL) in different clinical situations; therefore, we conducted a systematic review and meta-analysis to determine efficacy outcomes such as successful first attempt or time to perform endotracheal intubation as well as adverse events of VL vs. direct laryngoscopes (DL) for double-lumen intubation. First intubation attempt success rate was 87.9% for VL and 84.5% for DL (OR = 1.64; 95% CI: 0.95 to 2.86; I2 = 61%; p = 0.08). Overall success rate was 99.8% for VL and 98.8% for DL, respectively (OR = 3.89; 95%CI: 0.95 to 15.93; I2 = 0; p = 0.06). Intubation time for VL was 43.4 ± 30.4 s compared to 54.0 ± 56.3 s for DL (MD = -11.87; 95%CI: -17.06 to -6.68; I2 = 99%; p < 0.001). Glottic view based on Cormack-Lehane grades 1 or 2 equaled 93.1% and 88.1% in the VL and DL groups, respectively (OR = 3.33; 95% CI: 1.18 to 9.41; I2 = 63%; p = 0.02). External laryngeal manipulation was needed in 18.4% cases of VL compared with 42.8% for DL (OR = 0.28; 95% CI: 0.20 to 0.40; I2 = 69%; p < 0.001). For double-lumen intubation, VL offers shorter intubation time, better glottic view based on Cormack-Lehane grade, and a lower need for ELM, but comparable first intubation attempt success rate and overall intubation success rate compared with DL.
Project description:BackgroundData on the routine use of video-assisted laryngoscopy in peri-operative intubations are rather inconsistent and ambiguous, in part due to small populations and non-uniform outcome measures in past trials. Failed or prolonged intubation procedures are a reason for relevant morbidity and mortality. This study aims to determine whether video-assisted laryngoscopy (with both Macintosh-shaped and hyperangulated blades) is at least equal to the standard method of direct laryngoscopy with respect to the first-pass success rate. Furthermore, validated tools from the field of human factors will be applied to examine within-team communication and task load during this critical medical procedure.MethodsIn this randomized, controlled, three-armed parallel group design, multi-centre trial, a total of more than 2500 adult patients scheduled for perioperative endotracheal intubation will be randomized. In equally large arms, video-assisted laryngoscopy with a Macintosh-shaped or a hyperangulated blade will be compared to the standard of care (direct laryngoscopy with Macintosh blade). In a pre-defined hierarchical analysis, we will test the primary outcome for non-inferiority first. If this goal should be met, the design and projected statistical power also allow for subsequent testing for superiority of one of the interventions. Various secondary outcomes will account for patient safety considerations as well as human factors interactions within the provider team and will allow for further exploratory data analysis and hypothesis generation.DiscussionThis randomized controlled trial will provide a solid base of data in a field where reliable evidence is of major clinical importance. With thousands of endotracheal intubations performed every day in operating rooms around the world, every bit of performance improvement translates into increased patient safety and comfort and may eventually prevent significant burden of disease. Therefore, we feel confident that a large trial has the potential to considerably benefit patients and anaesthetists alike.Trial registrationClincalTrials.gov NCT05228288.Protocol version1.1, November 15, 2021.
Project description:OBJECTIVE:To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults. DESIGN:A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows. SETTING:Medical ICU in a tertiary, academic medical center. PATIENTS:Critically ill patients 18 years old or older. INTERVENTIONS:Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation. MEASUREMENTS AND MAIN RESULTS:Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy. CONCLUSIONS:In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.
Project description:BackgroundThe utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.MethodsWe systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models.ResultsOur meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I2 = 0%) compared to DL.ConclusionVL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.
Project description:BackgroundImmobilization of the cervical spine worsens tracheal intubation conditions. Various intubation devices have been tested in this setting. Their relative usefulness remains unclear.MethodsWe searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials comparing any intubation device with the Macintosh laryngoscope in human subjects with cervical spine immobilization. The primary outcome was the risk of tracheal intubation failure at the first attempt. Secondary outcomes were quality of glottis visualization, time until successful intubation, and risk of oropharyngeal complications.ResultsTwenty-four trials (1866 patients) met inclusion criteria. With alternative intubation devices, the risk of intubation failure was lower compared with Macintosh laryngoscopy [risk ratio (RR) 0.53; 95% confidence interval (CI) 0.35-0.80]. Meta-analyses could be performed for five intubation devices (Airtraq, Airwayscope, C-Mac, Glidescope, and McGrath). The Airtraq was associated with a statistically significant reduction of the risk of intubation failure at the first attempt (RR 0.14; 95% CI 0.06-0.33), a higher rate of Cormack-Lehane grade 1 (RR 2.98; 95% CI 1.94-4.56), a reduction of time until successful intubation (weighted mean difference -10.1 s; 95% CI -3.2 to -17.0), and a reduction of oropharyngeal complications (RR 0.24; 95% CI 0.06-0.93). Other devices were associated with improved glottis visualization but no statistically significant differences in intubation failure or time to intubation compared with conventional laryngoscopy.ConclusionsIn situations where the spine is immobilized, the Airtraq device reduces the risk of intubation failure. There is a lack of evidence for the usefulness of other intubation devices.
Project description:This observational study aimed to compare the glottic view between video and direct laryngoscopy for tracheal intubation in the surgical position for thyroid surgery with intraoperative neuromonitoring. Patients scheduled for elective thyroid surgery with intraoperative neuromonitoring were enrolled. After the induction of anesthesia, patients were positioned in the thyroid surgical posture with a standard inclined pillow under their head and back. An investigator assessed the glottic view using the percentage of glottic opening (POGO) scale and the modified Cormack-Lehane grade in direct laryngoscopy and then video laryngoscopy sequentially while using the same McGRATH™ MAC video laryngoscope at once, with or without external laryngeal manipulation, at the surgical position. A total of thirty-nine patients were participated in this study. Without external laryngeal manipulation, the POGO scale significantly improved during video laryngoscopy compared to direct laryngoscopy in the thyroid surgical position (60.0 ± 38.2% vs. 22.4 ± 23.8%; mean difference (MD) 37.6%, 95% confidence interval (CI) = [29.1, 46.0], P < 0.001). Additionally, with external laryngeal manipulation, the POGO scale showed a significant improvement during video laryngoscopy compared to direct laryngoscopy (84.6 ± 22.9% vs. 58.0 ± 36.3%; MD 26.7%, 95% CI = [18.4, 35.0] (P < 0.001). The superiority of video laryngoscopy was also observed for the modified Cormack-Lehane grade. In conclusion, video laryngoscopy with the McGRATH™ MAC video laryngoscope, when compared to direct laryngoscopy with it, improved the glottic view during tracheal intubation in the thyroid surgical position. This enhancement may potentially facilitate the proper placement of the electromyography tracheal tube and prevent tube displacement due to positional change for thyroid surgery.
