Videolaryngoscopy for all intubations: Is direct laryngoscopy obsolete?

Impact of Universal Use of the McGrath Videolaryngoscope as a Device for All Intubations in the Cardiac Operating Room. A Prospective Before-After VIDEOLAR-CAR Study

OBJECTIVE

Tracheal intubation in cardiac surgery patients has a higher incidence of difficult laryngoscopic views compared with patients undergoing other types of surgery. The authors hypothesized that using the McGrath Mac videolaryngoscope as the first intubation option for cardiac surgery patients improves the percentage of patients with "easy intubation" compared with using a direct Macintosh laryngoscope.

DESIGN

A prospective, observational, before-after study.

SETTING

At a tertiary-care hospital.

PARTICIPANTS

One thousand one hundred nine patients undergoing cardiac surgery.

INTERVENTION

Consecutive patients undergoing cardiac surgery were intubated using, as the first option, a Macintosh laryngoscope (preinterventional phase) or a McGrath Mac videolaryngoscope (interventional phase).

MEASUREMENTS AND MAIN RESULTS

The main objective was to assess whether the use of the McGrath videolaryngoscope, as the first intubation option, improves the percentage of patients with "easy intubation," defined as successful intubation on the first attempt, modified Cormack-Lehane grades of I or IIa, and the absence of the need for adjuvant airway devices. A total of 1,109 patients were included, 801 in the noninterventional phase and 308 in the interventional phase. The incidence of "easy intubation" was 93% in the interventional phase versus 78% in the noninterventional phase (p < 0.001). First-success-rate intubation was higher in the interventional phase (304/308; 98.7%) compared with the noninterventional phase (754/801, 94.1%; p = 0.005). Intubation in the interventional phase showed decreases in the incidence of difficult laryngoscopy (12/308 [3.9%] v 157/801 [19.6%]; p < 0.001), as well as moderate or difficult intubation (5/308 [1.6%] v 57/801 [7.1%]; p < 0.001).

CONCLUSIONS

The use of the McGrath videolaryngoscope as the first intubation option for tracheal intubation in cardiac surgery improves the percentage of patients with "easy" intubation," increasing glottic view and first-success-rate intubation and decreasing the incidence of moderate or difficult intubation.

The Clinical Usability Evaluation of an Attachable Video Laryngoscope in the Simulated Tracheal Intubation Scenario: A Manikin Study

The aim of this study was to assess the usefulness of an attachable video laryngoscope (AVL) by attaching a camera and a monitor to a conventional Macintosh laryngoscope (CML). Normal and tongue edema airway scenarios were simulated using a manikin. Twenty physicians performed tracheal intubations using CML, AVL, Pentax Airwayscope® (AWS), and McGrath MAC® (MAC) in each scenario. Ten physicians who had clinical experience in using tracheal intubation were designated as the skilled group, and another ten physicians who were affiliated with other departments and had little clinical experience using tracheal intubation were designated as the unskilled group. The time required for intubation and the success rate were recorded. The degree of difficulty of use and glottic view assessment were scored by participants. All 20 participants successfully completed the study. There was no difference in tracheal intubation success rate and intubation time in the normal airway scenario in both skilled and unskilled groups. In the experienced group, AWS had the highest success rate (100%) in the tongue edema airway scenario, followed by AVL (60%), MAC (60%), and CML (10%) (p = 0.001). The time required to intubate using AWS was significantly shorter than that with AVL (10.2 s vs. 19.2 s) or MAC (10.2 s vs. 20.4 s, p = 0.007). The difficulty of using AVL was significantly lower than that of CML (7.8 vs. 2.8; p < 0.001). For the experienced group, AVL was interpreted as being inferior to AWS but better than MAC. Similarly, in the unskilled group, AVL had a similar success rate and tracheal intubation time as MAC in the tongue edema scenario, but this was not statistically significant. The difficulty of using AVL was significantly lower than that of CML (8.8 vs. 3.3; p < 0.001). AVL may be an alternative for VL.

Comparison of Macintosh Laryngoscope, King Vision®, VividTrac®, AirAngel Blade®, and a Custom-Made 3D-Printed Video Laryngoscope for Difficult and Normal Airways in Mannequins by Novices-A Non-Inferiority Trial

Background: Endotracheal intubation (ETI) is a cornerstone of airway management. The gold standard device for ETI is still the direct laryngoscope (DL). However, video laryngoscopes (VLs) are now also widely available and have several proven advantages. The VL technique has been included in the major airway management guidelines. During the COVID-19 pandemic, supply chain disruption has raised demand for 3D-printed medical equipment, including 3D-printed VLs. However, studies on performance are only sparsely available; thus, we aimed to compare 3D-printed VLs to the DL and other VLs made with conventional manufacturing technology. Methods: Forty-eight medical students were recruited to serve as novice users. Following brief, standardized training, students executed ETI with the DL, the King Vision® (KV), the VividTrac® (VT), the AirAngel Blade® (AAB), and a custom-made 3D-printed VL (3DVL) on the Laerdal® airway management trainer in normal and difficult airway scenarios. We evaluated the time to and proportion of successful intubation, the best view of the glottis, esophageal intubation, dental trauma, and user satisfaction. Results: The KV and VT are proved to be superior (p < 0.05) to the DL in both scenarios. The 3DVL's performance was similar (p > 0.05) or significantly better than that of the DL and mainly non-inferior (p > 0.05) compared to the KV and VT in both scenarios. Regardless of the scenario, the AAB proved to be inferior (p < 0.05) even to the DL in the majority of the variables. The differences between the devices were more pronounced in the difficult airway scenario. The user satisfaction scores were in concordance with the aforementioned performance of the scopes. Conclusions: Based upon our results, we cannot recommend the AAB over the DL, KV, or VT. However, as the 3DVL showed, 3D printing indeed can provide useful or even superior VLs, but prior to clinical use, meticulous evaluation might be recommended.

Videolaryngoscopy as a primary intubation modality in obstetrics: A narrative review of current evidence

Pregnancy-related physiologic and anatomic changes affect oxygenation and airway management, and it is widely believed that airway difficulty may be more common in obstetric patients as a result. In addition, most obstetric intubations are performed under emergency conditions, and preoperative airway assessment poorly predicts airway management outcomes. These considerations necessitate special protocols for airway care in the obstetric population, and the evolution of the videolaryngoscope represents one of the most important milestones in recent decades. However, recommendations for the use of videolaryngoscopy in obstetrics remain unclear. A considerable body of evidence affirms that videolaryngoscopy improves laryngeal visualisation, increases first-attempt and overall intubation success rates, shortens intubation time, and facilitates team communication and education. In contrast, a significant number of studies have also reported conflicting results regarding comparative clinical outcomes and have highlighted other limitations regarding the adoption of videolaryngoscopy in routine obstetric care. Nevertheless, considering the peculiarities of obstetric intubation, the Macintosh-style videolaryngoscope can be suggested as the primary intubation device as it offers the benefits of both videolaryngoscopy and direct laryngoscopy. However, more rigorous evidence is needed to clarify the current blind spots and controversies regarding the role of videolaryngoscopy in obstetrics.

A Comparative Study of Video Laryngoscopy to Direct Laryngoscopy for Endotracheal Intubation in Pediatric Patients

Background

Direct laryngoscopy is the standard method for intubation in pediatric patients. The introduction of video laryngoscopy brought a paradigm shift in managing pediatric airways.

Objectives

We compared the tracheal intubation technique between direct and video laryngoscopy with McIntosh Blade 2 in pediatric patients 2 - 8 years of age requiring airway management. The glottic view and the first pass success rate were compared and analyzed.

Methods

An observational cross-sectional study was conducted with 120 children between 2 - 8 years with normal airways. They were divided into video laryngoscopy (Group V) and direct laryngoscopy (Group D). The primary outcome measures included time taken for intubation, number of attempts required, Cormack-Lehane glottic view, use of optimization maneuvers, the requirement of tube repositioning, and hemodynamic parameters before and after intubation.

Results

The time taken for intubation was longer in the video laryngoscopy group (group D, 24.28 sec vs. group V, 27.65 seconds (P = 0.01). The Cormack-Lehane glottic view was grade 1 in all the patients in the video laryngoscopy group, while only 35 children showed grade 1 in the direct laryngoscopy group. (P < 0.001). We observed a significant increase in both heart rate and mean arterial pressure in the video laryngoscopy group at 1, 3, 5, and 10 min after intubation (P < 0.001, P < 0.05).

Conclusions

The time taken for intubation was more in group V, but the glottic view was much better, and the requirement for external maneuvers was also less. Pressure response to intubation was more in group V compared to group D.

Comparison of self-assembled video laryngoscope versus McGrath MAC®: A randomised controlled trial

Background and Aims:

Video laryngoscopy highly improves the success rate for endotracheal intubation. However, commercially available video laryngoscopes such as McGrath MAC^® can be costly. An economical video laryngoscope was assembled by attaching a fibreoptic videoscope into a Macintosh laryngoscope. This randomised study aimed to compare the intubation time of this self-assembled modified Macintosh video laryngoscope (SAM-VL) and McGrath MAC^® (McGrath).

Methods:

This study enroled 62 adults scheduled for elective surgery under general anaesthesia with endotracheal intubation. The primary outcome was total intubation time. Secondary outcomes were the time for glottic visualisation (time A), time for tube insertion after glottic visualisation (time B), first-attempt intubation success rate, degree of glottic visualisation, and need for backward, upward, rightward pressure (BURP) assistance, complications, and user satisfaction. The tests used were: Kolmogorov-Smirnov and the Mann-Whitney test to analyse the data’s distribution and the primary outcome, respectively.

Results:

The median total intubation time in the SAM-VL group versus the McGrath was 63 s (27–114s) versus 74 s (40–133s), respectively (P = 0.032). Intubation time B was significantly faster, while the score of glottic visualisation and BURP assistance was significantly higher in the SAM-VL group. The differences in the rate of successful first attempts and complications were not statistically significant. SAM-VL users rated the ease of blade insertion and manoeuvrability, degree of glottic visualisation, and overall rating as very high.

Conclusion:

Endotracheal intubation using self-assembled modified video laryngoscope is faster and allows better glottis visualisation than McGrath MAC^®.