Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients – a systematic review and meta-analysis of randomized controlled trials

Abstract

BackgroundThere 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.MethodsWe 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.ResultsTwelve 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 < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48–0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (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 < 0.01) when using video laryngoscopy.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.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1885-9) contains supplementary material, which is available to authorized users.

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study

“…Most importantly, three-quarters of the studies systematically removed predicted difficult airways, the patient population in whom one would expect to observe a performance benefit from VL. 14 Our findings suggest that VL alone provides higher first-attempt success than DL aided by other maneuvers. Commonly employed visualization aids, such as ramping (especially in obese patients), laryngeal manipulation, and bougie use, have been studied and advocated for as minimally invasive, low-risk, and inexpensive maneuvers that potentially improves DL performance.…”

“…An additional three studies were prehospital investigations with one comparing a non‐video device (Airtraq) to DL. Most importantly, three‐quarters of the studies systematically removed predicted difficult airways, the patient population in whom one would expect to observe a performance benefit from VL . Our findings suggest that VL alone provides higher first‐attempt success than DL aided by other maneuvers.…”

Nationwide survey on training and device utilization during tracheal intubation in French intensive care units

“…The devices include metallic blades [13], stylets and bougies [14], and the more recently introduced videolaryngoscope, which improves visualization of the glottis and allows a second operator to provide assistance. However, in a randomized controlled trial reported in 2017 [15] and subsequent meta-analysis [16], the routine use of a videolaryngoscope in ICU patients failed to produce higher first-pass success rates compared to the Macintosh laryngoscope and was associated with a higher risk of serious adverse events. The 2018 guidelines issued by the Difficult Airway Society [8] recommend that a videolaryngoscope should be available in all ICUs and should be considered for the first attempt when laryngoscopy is predicted to be difficult [17].…”

Paediatric intubation in Australasian emergency departments: A report from the ANZEDAR

“…Use of a VL is an emerging technique in paediatric ED intubation and in our study was positively associated with FPS. Although a recent meta‐analysis suggested no improvement in outcomes in ED intubations with VL versus direct laryngoscopy, no children were included in that data set. The National Emergency Airway Registry investigators in North America found similar benefit in their report on 1053 paediatric ED intubations and taken together these findings are worthy of consideration and further study.…”