Videolaryngoscopy vs. direct Macintosh laryngoscopy in tracheal intubation in adults: a ranking systematic review and network meta‐analysis

Abstract

Summary Videolaryngoscopes are thought to improve glottic view and facilitate tracheal intubation compared with the Macintosh direct laryngoscope. However, we currently do not know which one would be the best choice in most patients undergoing anaesthesia. We designed this systematic review with network meta‐analyses to rank the different videolaryngoscopes and the Macintosh direct laryngoscope. We conducted searches in PubMed and a further five databases on 11 January 2021. We included randomised clinical trials with patients aged ≥16 years, comparing different videolaryngoscopes, or videolaryngoscopes with the Macintosh direct laryngoscope for the outcomes: failed intubation; failed first intubation attempt; failed intubation within two attempts; difficult intubation; percentage of glottic opening seen; difficult laryngoscopy; and time needed for intubation. We assessed the quality of evidence according to GRADE recommendations and included 179 studies in the meta‐analyses. The C‐MAC and C‐MAC D‐Blade were top ranked for avoiding failed intubation, but we did not find statistically significant differences between any two distinct videolaryngoscopes for this outcome. Further, the C‐MAC D‐Blade performed significantly better than the C‐MAC Macintosh blade for difficult laryngoscopy. We found statistically significant differences between the laryngoscopes for time to intubation, but these differences were not considered clinically relevant. The evidence was judged as of low or very low quality overall. In conclusion, different videolaryngoscopes have differential intubation performance and some may be currently preferred among the available devices. Furthermore, videolaryngoscopes and the Macintosh direct laryngoscope may be considered clinically equivalent for the time taken for tracheal intubation. However, despite the rankings from our analyses, the current available evidence is not sufficient to ensure significant superiority of one device or a small set of them over the others for our intubation‐related outcomes.

Mirror, mirror, on the wall, which is the best videolaryngoscope of them all? A reply

“…We thank Drs Hansel and Rogers for their comments regarding our work [1]. The authors raise concerns regarding our results for percentage of glottic opening and time for intubation [2].…”

Videolaryngoscopes versus direct laryngoscopes in children: Ranking systematic review with network meta‐analyses of randomized clinical trials

“…Videolaryngoscopy has been shown to improve the glottic view and reduce the number of attempts to successful intubation in adult patients compared with direct laryngoscopy. [1][2][3] However, their benefit for children is not equally clear. Data from the Pediatric Difficult Intubation Registry (PeDIR) have shown that videolaryngoscopy with both standard and hyperangulated blades has significantly higher success rates and fewer complications when compared to direct laryngoscopy in children who are difficult to intubate.…”

“…Other systematic reviews evaluating infants and older children have not found significant differences between videolaryngoscopy and direct laryngoscopy for a range of intubation‐related outcomes 9–11 . Recent studies have demonstrated that different videolaryngoscope blade designs may influence their performance 1,2,6 . Evaluating videolaryngoscopes as a single intervention may contribute to the lack of significant difference in most pairwise analyses available in children.…”

Mirror, mirror, on the wall, which is the best videolaryngoscope of them all?

“…We enjoyed reading the ranking systematic review and network meta-analysis by de Carvalho et al [1]. Randomised…”

“…We enjoyed reading the ranking systematic review and network meta‐analysis by de Carvalho et al [1]. Randomised controlled trials comparing videolaryngoscopes have blossomed over the past 5 years since the publication of the last Cochrane review by Lewis et al [2] on the topic, and an updated summary of the evidence is indeed overdue.…”