Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis

Abstract

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees.Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice.Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Subanalysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students.Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.

Unexpected Lung Collapse Following Chest Tube Insertion for Pneumothorax Drainage in an Intubated Patient Due to Dislocation of the Endotracheal Tube

“…The tube must be adjusted according to the patient's dimensions and carefully secured at the proper distance at the incisors. Additional checks that are essential by the anesthetist to find out malplacement of an endotracheal tube include observation for symmetrical chest movements (rise and fall during positive pressure ventilation, indicating proper inflation of both lungs), colorimetric capnography (it measures the concentration of carbon dioxide in exhaled air), video laryngoscopy and fiberoptic bronchoscopy (direct visualization of the tube passing through the vocal cords), use of depth markers, and ultrasonography (used to visualize the trachea and confirm endotracheal tube placement, particularly in challenging cases or when other methods are inconclusive) [6][7][8]. Furthermore, the surgeon should consistently monitor the movements of the pleura on both sides, which are influenced by the inflation and deflation of the lungs following mid-sternotomy.…”

Styletubation versus Laryngoscopy: A New Paradigm for Routine Tracheal Intubation

“…While experienced airway operators may be skillful in various intubating tools and techniques, it is understandable that the novices (medical students, residents, non-anesthesiology trainees) might encounter difficulties during the learning and practice. Therefore, various training modules and assessment of tracheal intubation (e.g., VL and DL) for medical personnel have been reported [167][168][169][170]. Training inexperienced novice personnel with a VL, e.g., following a short teaching program, improves the success rate and time for tracheal intubation in patients with normal airways [171] or in airway manikin with various simulated clinical scenarios [172].…”

“…Different intubating device design itself (e.g., DL, channeled VL) may also affect novices' learning curve (e.g., initial success rate, intubating time) [170]. Learners' behavior, personality, and prior experiences might also affect the learning curve and success rate of various intubating tools.…”

Styletubation versus Laryngoscopy: A New Paradigm for Routine Tracheal Intubation

“…While experienced airway operators may be skillful in various intubating tools and techniques, it is understandable that the novices (medical students, residents, and non-anesthesiology trainees) might encounter difficulties during learning and practice. Therefore, various training modules and assessments of tracheal intubation (e.g., VL and DL) for medical personnel have been reported [167][168][169][170]. Training inexperienced novice personnel with a VL, e.g., following a short teaching program, improves the success rate and time for tracheal intubation in patients with normal airways [171] or in airway manikins with various simulated clinical scenarios [172].…”