Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults
Summary by Nicholas Prescurea, MD 9.19.23
https://www.nejm.org/doi/pdf/10.1056/NEJMoa2301601?articleTools=true
Clinical Hypothesis: Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults.
Video laryngoscopy is a safe, alternative method for tracheal intubation which can produce a better vocal cord view and can lead to higher success rate of intubation.
Providers with less experience can successfully intubate patients with higher success rates using VL when compared to DL
Safety outcomes between VL vs. DL are similar with no significant difference among the study groups in this trial.
Summary:
Background:
This study aimed to evaluate the efficacy of video-assisted laryngoscopy vs. direct laryngoscopy in increasing the likelihood of a successful first attempt for tracheal intubation in critically ill patients in an ICU and ED room setting. Given both methods are commonly used for tracheal intubation, the study aimed at collecting experimental data to evaluate the given techniques.
Study Design:
This study was a pragmatic, multicenter, unblended, randomized, parallel-group trial at 17 sites (7 EDs + 10 ICUs) in the United States. Patients were assigned to a 1:1 random ratio to undergo either DL vs. Video laryngoscopy.
Methods:
A total of 1417 patients were selected to participate in the trial, 705 underwent video laryngoscopy and 712 underwent DL.
Inclusion criteria:
Critically ill adults (age > 18) undergoing oral tracheal intubation with the use of laryngoscopy were included in the study design.
Exclusion criteria:
Pregnancy, prisoners, and emergent endotracheal intubation need to preclude randomization and operator/provider determination that DL or video laryngoscopy was unwarranted for a first attempt at tracheal intubation.
Primary outcome:
Successful intubation on the first attempt with either DL or video laryngoscopy
Secondary outcome:
Occurrence of severe complications during intubation such as hypoxemia, hypotension, new vasopressor requirement, cardiac arrest, or death.
Results:
Successful intubation using VL occurred in 600/705 patients, 85.1%. For the DL subgroup, first-attempt intubation success occurred in 504/712 patients or 70.85. An absolute risk difference of 14.3% resulted in a P-value < 0.0001.
Severe complications occurred in 151 total patients in the VL group compared to 149 in the DL, which did not reveal any statistical difference in safety outcomes.
A view of most of the vocal cords (grade 1 on the Cormack–Lehane grading scale) was reported in 76.3% of the patients in the video-laryngoscope group, as compared with 44.7% of the patients in the direct-laryngoscope group (absolute risk difference, 31.6 percentage points;
Among the operators who had performed fewer than 25 intubations, the absolute difference between the two groups in the incidence of successful intubation on the first attempt was 26.1 percentage points (95% CI, 15.4 to 36.8
Successful intubation on the first attempt without the occurrence of a severe complication was achieved in 484 patients (68.7%) in the video laryngoscope group and 420 patients (59.0%) in the direct-laryngoscope group (absolute risk difference, 9.7 percentage points;
Failure to intubate the trachea on the first attempt because of an inadequate view of the vocal cords occurred in 26 patients (3.7%) in the video-laryngoscope group and 123 patients (17.3%) in the direct-laryngoscope group (absolute risk difference, −13.6 percentage points; 95% CI, −16.8 to −10.3
Discussion/conclusion:
Among critically ill adults in this multicenter, randomized trial, the use of a video laryngoscope for tracheal intubation resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. Study strengths include randomization of patients to either study groups, variety of “operator skill level/experience” and multiple different forms of DL and VL tools used which increases generalizability. Study weakness includes that all the intubations occurred in an emergency department or ICU. This data set cannot be applied to OR settings.