Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a Cochrane Systematic Review

Abstract

Difficulties with tracheal intubation commonly arise and impact patient safety. This systematic review evaluates whether videolaryngoscopes reduce intubation failure and complications compared with direct laryngoscopy in adults. We searched CENTRAL, MEDLINE, Embase and clinicaltrials.gov up to February 2015, and conducted forward and backward citation tracking. We included randomized controlled trials that compared adult patients undergoing laryngoscopy with videolaryngoscopy or Macintosh laryngoscopy. We did not primarily intend to compare individual videolaryngoscopes. Sixty-four studies (7044 participants) were included. Moderate quality evidence showed that videolaryngoscopy reduced failed intubations (Odds Ratio (OR) 0.35, 95% Confidence Interval (CI) 0.19-0.65) including in participants with anticipated difficult airways (OR 0.28, 95% CI 0.15-0.55). There was no evidence of reduction in hypoxia or mortality, but few studies reported these outcomes. Videolaryngoscopes reduced laryngeal/airway trauma (OR 0.68, 95% CI 0.48-0.96) and hoarseness (OR 0.57, 95% CI 0.36-0.88). Videolaryngoscopy increased easy laryngeal views (OR 6.77, 95% CI 4.17-10.98) and reduced difficult views (OR 0.18, 95% CI 0.13-0.27) and intubation difficulty, typically using an 'intubation difficulty score' (OR 7.13, 95% CI 3.12-16.31). Failed intubations were reduced with experienced operators (OR 0.32, 95% CI 0.13-0.75) but not with inexperienced users. We identified no difference in number of first attempts and incidence of sore throat. Heterogeneity around time for intubation data prevented meta-analysis. We found evidence of differential performance between different videolaryngoscope designs. Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates. Videolaryngoscopes may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a videolaryngoscope reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a videolaryngoscope affects time required for intubation.

Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

“…Thus, techniques that can reduce the number of attempts at endotracheal intubation and the duration of the procedure and minimize the proximity between the operator and the patient, should be prioritized, potentially reducing the risk of complications in hypoxic COVID-19 patients. In a systematic review including 64 studies and 7044 patients, video-laryngoscopy reduced the risk of failed intubation (OR 0.35, 95% CI 0.19-0.65), without a significant impact upon the proportion of successful first-pass attempts (OR 0.79, 95% CI 0.48-1.3), hypoxia (OR 0.39, 95% CI 0.1-1.44), or time for tracheal intubation [30,31]. In patients with difficult airways, the first-attempt success rate may be improved with video-laryngoscopy [32].…”

“…Summary of recommendations on the initial management of hypoxic COVID-19 patientsInvasive Mechanical VentilationRecommendation30. In mechanically ventilated adults with COVID-19 and ARDS, we recommend using low tidal volume (Vt) ventilation (Vt 4-8 mL/kg of predicted body weight), over higher tidal volumes (Vt > 8 mL/kg).…”

Awake Orotracheal Intubation with the McGrath Mac X-Blade in a Patient with Expected Difficult Airway

“…A Cochrane database concluded that failed intubations were significantly fewer when videolaryngoscopy was used in patients with an anticipated difficult airway. 5 In our clinic, the need for fiberoptic intubation dramatically decreased after using the videolaryngoscopy in expected difficult airways.…”

Paediatric intensive care and neonatal intensive care airway management in the United Kingdom: the PIC‐NIC survey

“…Research into videolaryngoscope use has been complicated by the large number of different devices currently available, all classified as ‘videolaryngoscopes’, but with differing design, instructions for use and performance characteristics . In adults, different videolaryngoscopes have different performance profiles, with some outperforming others , and it is highly likely that the same is true in paediatrics and neonates. Although adult techniques cannot necessarily be transferred to paediatric practice, this is a fast‐moving field and it is likely that there will be an ongoing debate regarding videolaryngoscopy in paediatrics and neonatal practice in the next few years.…”