Video laryngoscopy effective at reducing intubation attempts, improving intubation success

Key takeaways:

• More than one intubation attempt was required in just 1.7% of 4,413 surgical procedures using video laryngoscopy.
• Meanwhile, intubation failure occurred in 0.27% of surgical procedures with video laryngoscopy.

Hyperangulated video laryngoscopy among patients being intubated increased initial intubation attempt success and reduced the number of intubation attempts vs. direct laryngoscopy, a study showed.

According to Kurt Ruetzler, MD, an associate professor of anesthesiology at the Cleveland Clinic, and colleagues, video laryngoscopy “may improve visualization of airways but is sometimes associated with prolonged and failed intubation attempts.”

“The extent to which video laryngoscopy might facilitate intubation in patients undergoing surgical procedures during routine clinical practice remains unclear,” they wrote in JAMA.

In a cluster randomized clinical trial, two sets of 11 operating rooms at a single academic hospital were randomly assigned on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt among patients who were undergoing elective or emergent cardiac, thoracic or vascular surgical procedures and required single-lumen endotracheal intubation for general anesthesia.

The primary outcome was the number of operating room intubation attempts per surgical procedure, whereas the secondary outcome was intubation failure, defined “by either the responsible clinician switching to an alternative laryngoscopy device for any reason at any time or by more than three intubation attempts,” Ruetzler and colleagues wrote.

The study included 8,429 surgical procedures with 7,736 patients (mean age, 66 years; 35% women), among whom 85% had elective surgical procedures.

The researchers found that more than one intubation attempt was required in 1.7% of 4,413 surgical procedures randomly assigned to receive video laryngoscopy vs. 7.6% of 4,016 surgical procedures randomly assigned to receive direct laryngoscopy, with an estimated proportional OR for the number of intubation attempts of 0.2 (95% CI, 0.14-0.28).

Intubation failure occurred in 0.27% of 4,413 surgical procedures using video laryngoscopy vs. 4% of 4,016 surgical procedures using direct laryngoscopy (RR = 0.06; 95% CI, 0.03-0.14), for an unadjusted absolute risk difference of 3.7% (95% CI, 4.4% to 3.2%).

Ruetzler and colleagues noted that airway injuries were similar for each group, at an incidence rate of 1%.

They added that the improvements seen with video laryngoscopy may be clinically important, “as several large observation studies and randomized trials reported, that multiple intubation attempts promote complications including aspiration, hypoxemia, airway injury, and even death.”

There were multiple limitations in the study, however. For example, the findings may not be generalizable to other institutions due to the trial’s single-center setting, and results could differ with nonanesthesia-trained clinicians.

Still, the findings “suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures,” the researchers concluded.