More successful first attempt intubations with video laryngoscopy
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Key takeaways:
- Video vs. direct laryngoscopy prevents first attempt intubation failure in about one out of every seven patients.
- Intubation failure due to poor view of vocal cords was more common with direct laryngoscopy.
When clinicians used video vs. direct laryngoscopes for emergency tracheal intubation, they had higher rates of successful first attempts, according to study results published in The New England Journal of Medicine.
“The average clinician caring for critically ill or injured adults in the U.S. probably performs intubation with the frequency and experience represented in this trial,” Matthew E. Prekker, MD, MPH, associate professor of emergency medicine and internal medicine at Hennepin County Medical Center, told Healio. “The significance [of this study] for practicing emergency physicians and intensivists is that video laryngoscopy should be used on the first attempt at orotracheal intubation, rather than direct laryngoscopy, to improve the efficiency (and by extension, the safety) of this critical procedure.”
Prekker and colleagues analyzed 1,417 adults (median age, 55 years) who required tracheal intubation in a multicenter, unblinded, randomized parallel group trial (DEVICE) across seven EDs and 10 ICUs to assess which type of laryngoscopy, video (n = 705) or direct (n = 712), leads to more successful intubations in one attempt.
Researchers also compared the frequency of severe complications — such as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest or death— between the video laryngoscope group and the direct laryngoscope group.
Notably, enrollment was ended at the preplanned interim analysis due to efficacy, a result that Prekker told Healio was “somewhat surprising.”
An emergency medicine resident or critical care fellow carried out the intubation procedure in 91.5% of the included patients. Of the 387 operators who performed these intubations, the median number of intubations they had performed before this study was 50.
Intubation success rate
Researchers found that more patients who were intubated with use of a video laryngoscope achieved successful intubation in the first attempt compared with patients who underwent the procedure with use of a direct laryngoscope (85.1% vs. 70.8%).
“Our final effect size (14.3 percentage points higher first attempt intubation success in the video laryngoscope group) was remarkable,” Prekker said.
“Prior randomized trials of video vs. direct laryngoscopy used a less stringent definition of first attempt success (ie, successful intubation on the first laryngoscope blade insertion into the mouth),” Prekker told Healio. “To allow an ‘apples-to-apples’ comparison between trials, we report first attempt success with one laryngoscope insertion occurred more frequently in the video laryngoscope group (90.3%) than in the direct laryngoscope group (77.3%), highlighting that the first attempt success with direct laryngoscopy was similar to or better than that reported in previous trials.”
When evaluating intubation success among clinicians with a comparable number of past intubations using each type of laryngoscope, use of the video laryngoscope led to more successful intubations in one attempt (absolute risk difference, 13.5 percentage points; 95% CI, 7.7 to 19.4). This finding continued to appear in subgroup analyses assessing success of both types of laryngoscopes by hospital location, BMI, presence of traumatic injury, anticipated difficulty of intubation, clinician’s previous number of intubations and proportion of previous intubations performed with a video laryngoscope.
“I was surprised that video laryngoscopy outperformed direct laryngoscopy even among the subgroup of cases where the operator (the clinician performing the intubation procedure) had done most (> 75%) of their previous intubation using a direct laryngoscope,” Prekker told Healio. “These findings are evidence of a consistent benefit for clinicians and patients when the video laryngoscope that the clinician is most comfortable with is used on the initial attempt to perform this high-risk procedure.”
In the sub analysis of operators who had previously performed fewer than 25 intubations, more successful first attempts were recorded by those who used the video laryngoscope than the direct laryngoscope (80% vs. 53.9%).
“A video laryngoscope may especially benefit operators with limited prior intubation experience because it consistently offers a better view of upper airway anatomy to guide the endotracheal tube into the trachea, or perhaps because another clinician (also viewing the video screen during laryngoscopy) can provide real time feedback on technique to the operator,” Prekker told Healio. “My opinion is that a video laryngoscope with a Macintosh, or standard geometry, blade shape offers maximal flexibility — for the operator, it can be used as a video or a direct laryngoscope and performs well in the teaching or academic environment where it’s still necessary to learn both techniques.”
Intubation complications
The prevalence of severe complications during the procedure were comparable between the two laryngoscopes, with 151 patients (21.4%) in the video group and 149 patients (20.9%) in the direct group experiencing a complication (absolute risk difference, 0.5 percentage points; 95% CI, –3.9 to 4.9).
When assessing why clinicians could not intubate patients on the first attempt, researchers found that more patients in the direct laryngoscope group had a failed intubation due to a poor view of their vocal cords than patients in the video laryngoscope group (17.3% vs. 3.7%).
Compared with a direct laryngoscope, use of a video laryngoscope also led to a shorter median length of intubation (46 seconds vs. 38 seconds).
Lastly, both groups demonstrated comparable rates of esophageal intubation (video, 6 patients vs. direct, 9 patients), injury to teeth (video, 3 patients vs. direct, 2 patients) and aspiration (video, 7 patients vs. direct, 12 patients), according to researchers.
“These interventions were not tested in the operating room or among the most experienced anesthesiologists, so it’s unclear how our results apply in that setting,” Prekker told Healio.
Reference:
- Study shows video laryngoscope increases successful intubation on first attempt. https://news.vumc.org/2023/06/16/study-shows-video-laryngoscope-increases-successful-intubation-on-first-attempt/. Published June 16, 2023. Accessed June 19, 2023.
For more information:
Matthew E. Prekker, MD, MPH, can be reached at matthew.prekker@hcmed.org.