Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients

Abstract

Intensive Care and Sepsis (CRICS) Group IMPORTANCE In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. OBJECTIVE To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients.DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up.INTERVENTIONS Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia. MAIN OUTCOMES AND MEASURESThe primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications. RESULTS Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; P = .37).CONCLUSIONS AND RELEVANCE Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels.

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

“…Although randomized controlled trials have called into question the benefit of VL (24)(25)(26)(27), there are several important limitations to each of these studies to consider when interpreting the comparison between DL and VL. In some, patients were excluded either directly (25) or indirectly (24,26) for a history of a difficult intubation or anticipated difficult intubation.…”

“…In some, patients were excluded either directly (25) or indirectly (24,26) for a history of a difficult intubation or anticipated difficult intubation. The use of endotracheal tubes without a stylet may have also influenced outcomes (27).…”

The dangerous airway: reframing airway management in the critically ill

“…Studies comparing devices, techniques, or methods often focus either on the anticipated difficult airway, which is poorly predicted, deliberately exclude difficult airway patients, or isolate one aspect while ignoring the others (e.g. apneic oxygenation while ignoring preoxygenation) (4)(5)(6)(7)(8)(9)(10)(11). Conversely, focusing on laryngoscopy-related complications ignores significant danger in airway management from incomplete preparation and difficult physiology-related complications, especially considering most patients are intubated in the first two attempts.…”

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

“…Four RCTs enrolling 678 patients were included [60][61][62][63], and compared with direct laryngoscopy, videolaryngoscopy did not significantly improve first-attempt success rate (RR 1.17, 95% CI 0.89-1.53). In videolaryngoscopy groups, poor glottis visualization was less common (RR 0.30, 95% CI 0.14-0.64), and incidence of esophageal intubation was lower (RR 0.31, 95% CI 0.11-0.90).…”

“…The MACMAN trial (McGrath Mac Videolaryngoscope Versus Macintosh Laryngoscope for Orotracheal Intubation in the Critical Care Unit) is a multicentre, open-label, randomized controlled superiority trial published in JAMA [63]. It was a multicenter, randomized, openlabel trial, which included all ICU patients that needed orotracheal intubation.…”