Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.
Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016.
To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings.
We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches.
We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs.
We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation.
We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit. We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%).
VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.
Hansel J
，Rogers AM
，Lewis SR
，Cook TM
，Smith AF
... -
《Cochrane Database of Systematic Reviews》
Comparison of direct and indirect images and hemodynamic response of two different video laryngoscopes to tracheal intubation.
The aim of this study was to compare the effects of two different videolaryngoscopes (VLs) on direct (through the mouth) and indirect (screen images) laryngoscopy and to evaluate their effects on hemodynamic response.
A total of 70 patients between the ages of 18 and 65 years with ASA I-III physical status, planned for general anesthesia, with an expected difficult airway, were included in the study. Patients were enrolled in the study between 02/ 2022 and 06/ 2022. Patients were randomly divided into two groups. McGrath video laryngoscope was used in Group MC and Hugemed video laryngoscope was used in Group H. Modified Cormack Lehane and POGO scores (Percentage of glottic opening) of all patients on direct and indirect laryngoscopy were evaluated and recorded and then orotracheal intubation was performed. Demographic data, ASA status, Mallampati classification, thyromental distances and mouth opening were recorded. Standard monitoring was applied to all patients. During intubation, endotracheal intubation time, number of attempts, intubation-related complications and sore throat were recorded. Hemodynamic parameters (mean arterial pressure, peripheral oxygen saturation values) were recorded before, after induction and after intubation.
There was no difference between the groups in terms of descriptive characteristics (p > 0.05). When direct and indirect POGO scores were compared in group MC, no difference was found between the patients (p > 0.05). When direct and indirect POGO scores were compared, no difference was found between patients in Group H (p > 0.05). The mean POGO VL indirect score of Group H patients was found to be significantly higher than that of Group MC (p < 0.035) Both VLs showed similar results in terms of intubation time, number of attempts and hemodynamic findings.
McGrath and Hugemed videolaryngoscopes provide a good laryngeal view with similar Cormack Lehane scores during non-difficult endotracheal intubation and facilitate successful intubation by maintaining hemodynamic stability. It was observed that the Hugemed VL had a better indirect POGO score, but the images provided by the blades of both VLs on direct laryngoscopy allowed intubation.
NCT06649526. Clinical trials registration date 17/10/2024 ''retrospectively registered'".
Sezen Ö
，Şimşek T
，Şimşek AK
，Arslan G
，Saracoglu KT
，Saracoglu A
... -
《-》
McGrath MAC Versus Three-Dimensional Printed Video Laryngoscopes: A Randomized, Manikin-Simulated Noninferiority Controlled Study with Medical Students.
Proficiency in endotracheal intubation (ETI) is essential for medical professionals and its training should start at medical schools; however, large caseload may be required before achieving an acceptable success rate with direct laryngoscopy. Video laryngoscopy has proven to be an easier alternative for intubation with a faster learning curve, but its availability in medical training may be an issue due to its high market prices. We devised a low-cost 3-dimensionally printed video laryngoscope (3DVL) and performed a randomized trial to evaluate if the intubation success rate on the first attempt with this device is noninferior to a standard commercially available video laryngoscope (STVL).
Two hundred and nine medical students from 5 medical schools were enrolled and randomized to start with the STVL (McGrath MAC) or the 3DVL. Four stations (standard airway using the STVL/3DVL and difficult airway using the STVL/3DVL) were set to simulate ETI with standard Airway Management Trainer manikins (Laerdal Medical Ltd.). The noninferiority margin of 7.5% was defined for the success rate on the first attempt, considering the difference in proportions between the STVL (expected to be higher) and 3DVL groups.
Regarding the standard airway station, 60.7% (n = 65) of the students successfully performed TI on the first attempt with the STVL within the established timeframe, compared to 36.3% (n = 37) of the students using the 3DVL. This represented a difference of 24.4% (95% confidence interval, 17.5%-31.3%). Considering the difficult airway station, the success rates on the first intubation attempt with the 2 VLs did not differ.
The 3DVL was inferior in achieving first-attempt intubation when compared with the STVL with a difference in success rate >7.5% margin in simulated scenarios with medical students. Tracheal intubation might require a set of psychomotor skills for which the McGrath MAC device is superior to the low-cost alternative.
Detoni PB
，Nascimento JS
，Araújo Azi LMT
，Pustilnik AG
，Gusmão-Cunha A
，Módolo NSP
，Campos GO
，de Almeida VS
，Cambui JPMM
，de Almeida VS
，Alves RL
... -
《-》
Impact of universal use of the McGrath videolaryngoscope as the first option for all intubations in the operating room: The multicentre prospective before-after VIDEOLAR-SURGERY study protocol.
Standard tracheal intubation performed in the operating room is based on direct laryngoscopy using a standard Macintosh laryngoscope. Several authors recommend the universal use of a video laryngoscope as the first option for all intubations, regardless of whether the patient has predictors of a difficult airway or not. We hypothesize that using the McGrath video laryngoscope as the first intubation option increases the frequency of patients with easy intubation, and decreases intubation-related complications.
The VIDEOLAR-SURGERY trial is a prospective, multicentre, open-label, interventional, before-after study. In the pre-implementation period (non-interventional phase, 6-9 months [2600 intubations]), 35 anaesthesiologists from 8 hospitals perform all tracheal intubations for an elective or urgent surgical procedure using the standard Macintosh direct laryngoscope as the first intubation option. During the implementation period (2 months), each anaesthesiologist is given a McGrath Mac video laryngoscope and trained in its use. During the post-implementation period (interventional-phase, 6-9 months [2600 intubations]), the 35 anaesthesiologists perform all tracheal intubations using a McGrath Mac video laryngoscope as the first intubation option. The main objective of this study is to evaluate whether the use of a McGrath Mac video laryngoscope as the first intubation option increases the percentage of patients with easy intubation compared with the standard Macintosh laryngoscope.
The study protocol was approved on 2 May 2023 by the Ethics Committee of Galicia, Spain (CEI-SL, code No. 2023-177), and was registered on the Clinicaltrials.gov clinical trials registry under No. NCT NCT05850260. Informed consent is required. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. If video laryngoscopy improves easy intubation compared with Macintosh direct laryngoscopy in all operating room intubations, its use may well become standard practice, thereby decreasing the risks of intubation-related complications.
Taboada M
，Estany-Gestal A
，Rama-Maceiras P
，Orallo MA
，Bermúdez M
，Barreiro C
，Gómez L
，Amor M
，Otero F
，Fernández J
，Molins N
，Amate JJ
，Bascuas B
，Rey R
，Alonso MC
，Castro MJ
，Sarmiento A
，Dos Santos L
，Nieto C
，Paredes S
，Velasco A
，Taboada C
，Martín L
，Campaña D
，Mosquera E
，Novoa C
，Varela S
，da Silva L
，Domínguez E
，Bedoya A
，Gómez AI
，Estévez M
，Martínez P
，Sotojove R
，Naveiro A
，Díaz C
，Ruido R
，Mirón P
，González M
，Francisco C
，Regueira J
，Peiteado M
，Eiras M
，Paz E
... -
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