Comparison between Glidescope, Airtraq and Macintosh laryngoscopy for emergency endotracheal intubation in intensive care unit: Randomized controlled trial

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024.

STUDY SELECTION

We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945).

DATA SYNTHESIS

We included 20 RCTs ( n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL.

CONCLUSIONS

In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The 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.

METHODS

We 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.

RESULTS

Our 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.

CONCLUSION

VL 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.

Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review

Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.

Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

BACKGROUND

Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

METHODS

In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

RESULTS

The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

CONCLUSIONS

Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).

Comparison of video laryngoscopy with direct laryngoscopy for intubation success in critically ill patients: a systematic review and Bayesian network meta-analysis

Introduction

This review compares the efficacy of video laryngoscopy (VL) with direct laryngoscopy (DL) for successful tracheal intubation in critically ill or emergency-care patients.

Methods

We searched the MEDLINE, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) that compared one or more video laryngoscopes to DL. Sensitivity analysis, subgroup analysis, and network meta-analysis were used to investigate factors potentially influencing the efficacy of VL. The primary outcome was the success rate of first-attempt intubation.

Results

This meta-analysis included 4244 patients from 22 RCTs. After sensitivity analysis, the pooled analysis revealed no significant difference in the success rate between VL and DL (VL vs. DL, 77.3% vs. 75.3%, respectively; OR, 1.36; 95% CI, 0.84-2.20; I² = 80%; low-quality evidence). However, based on a moderate certainty of evidence, VL outperformed DL in the subgroup analyses of intubation associated with difficult airways, inexperienced practitioners, or in-hospital settings. In the network meta-analysis comparing VL blade types, nonchanneled angular VL provided the best outcomes. The nonchanneled Macintosh video laryngoscope ranked second, and DL ranked third. Channeled VL was associated with the worst treatment outcomes.

Discussion

This pooled analysis found, with a low certainty of evidence, that VL does not improve intubation success relative to DL. Channeled VL had low efficacy in terms of intubation success compared with nonchanneled VL and DL.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285702, identifier: CRD42021285702.

DirEct versus VIdeo LaryngosCopE (DEVICE): protocol and statistical analysis plan for a randomised clinical trial in critically ill adults undergoing emergency tracheal intubation

INTRODUCTION

Among critically ill patients undergoing orotracheal intubation in the emergency department (ED) or intensive care unit (ICU), failure to visualise the vocal cords and intubate the trachea on the first attempt is associated with an increased risk of complications. Two types of laryngoscopes are commonly available: direct laryngoscopes and video laryngoscopes. For critically ill adults undergoing emergency tracheal intubation, it remains uncertain whether the use of a video laryngoscope increases the incidence of successful intubation on the first attempt compared with the use of a direct laryngoscope.

METHODS AND ANALYSIS

The DirEct versus VIdeo LaryngosCopE (DEVICE) trial is a prospective, multicentre, non-blinded, randomised trial being conducted in 7 EDs and 10 ICUs in the USA. The trial plans to enrol up to 2000 critically ill adults undergoing orotracheal intubation with a laryngoscope. Eligible patients are randomised 1:1 to the use of a video laryngoscope or a direct laryngoscope for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is the incidence of severe complications between induction and 2 min after intubation, defined as the occurrence of one or more of the following: severe hypoxaemia (lowest oxygen saturation <80%); severe hypotension (systolic blood pressure <65 mm Hg or new or increased vasopressor administration); cardiac arrest or death. Enrolment began on 19 March 2022 and is expected to be completed in 2023.

ETHICS AND DISSEMINATION

The trial protocol was approved with waiver of informed consent by the single institutional review board at Vanderbilt University Medical Center and the Human Research Protection Office of the Department of Defense. The results will be presented at scientific conferences and submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05239195).

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation

BACKGROUND

Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016.

OBJECTIVES

To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation.

MAIN RESULTS

We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit.  We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%).

AUTHORS' CONCLUSIONS

VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.

A Comparative Evaluation of Hemodynamic Response and Ease of Intubation using Airtraq and McCoy Laryngoscope

Background:

Various airway gadgets have been devised to overcome difficult airway scenario in anesthesia practice. It includes simple rigid laryngoscope to complex fiber-optic intubating devices; however, there is weak evidence to support the superiority of one device over the other.

Aims and Objective:

The ease of intubation, time and the hemodynamic variability between two groups during intubation are considered as the primary outcome measures.

Materials and Methods:

In this prospective study, 60 patients of either sex undergoing elective surgery who required tracheal intubation were included. All the patients of age between 20 and 50 years with the American Society of Anesthesiologists Classes I and II were divided into the following two groups: Group AT (n = 30): the intubation was performed using AT laryngoscope and Group-MC (n = 30); the intubation was performed using MC laryngoscope. The following intubating parameters were recorded: ease of intubation (Grade-I–IV), mean time of laryngoscopy and intubation, Cormack–Lehane grade, and the percentage of glottis opening (POGO) score. The vital parameters such as heart rate (HR) and mean arterial blood pressure (MABP) were recorded only after premedication, and it was taken as the baseline value. These parameters were again recorded at 1 min, 3 min, 5 min, and 10 min after laryngoscopy and intubation. The incidences of sore throat were recorded just before discharge from the recovery room till 24 h of surgery. All these parameters were compared between these two groups using the Student's t-test and Chi-square test.

Results:

There was no significant difference in age, sex, weight, and Mallampati grading between the two groups. More than 30% of patients in Group AT were intubated without an external aid than the Group MC (P < 0.05). In Group AT, the mean time of intubation was 13.5 ± 5.72 s when compared to 15.63 ± 7.28 s in Group MC (P > 0.05). The Cormack–Lehane grade and POGO score were better in the AT group than that of the MC group. The HR at 1 min in Group AT was 101.83 ± 14.50 and in Group MC, it was 108.93 ± 12.86 (P < 0.05) and after 3 min, it was 98.66 ± 12.60 and 111.53 ± 11.67 (P < 0.05), respectively. The MABP was 107.17 ± 9.03 in Group AT compared to 116 ± 10.12 in Group MC (P < 0.05) at 1 min postintubation. The incidences of sore throat were similar in both the groups.

Conclusion:

The AT laryngoscope is better than MC in terms of the ease of intubation, better glottis view, and hemodynamic stability. However, the incidences of sore throat in both groups were comparable.