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Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

ABSTRACT:

Background

The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.

Methods

We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I² statistics. All outcomes were submitted to random-effect models.

Results

Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I² = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I² = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I² = 0%) compared to DL.

Conclusion

VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.

SUBMITTER: Araujo B

PROVIDER: S-EPMC10759602 | biostudies-literature | 2024 Jan

REPOSITORIES: biostudies-literature

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Publications

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

Araújo Beatriz B Rivera André A Martins Suzany S Abreu Renatha R Cassa Paula P Silva Maicon M Gallo de Moraes Alice A

Critical care (London, England) 20240102 1

<h4>Background</h4>The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.<h4>Methods</h4>We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency d ...[more]

PMID: 38167459

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Project description:BackgroundRecent trials showed that video laryngoscopy (VL) did not yield higher first-attempt tracheal intubation success rate than direct laryngoscopy (DL) and was associated with higher rates of complications. Tracheal intubation can be more challenging in the general ward than in the intensive care unit. This study aimed to investigate which laryngoscopy mode is associated with higher first-attempt intubation success in a general ward.MethodsThis is a retrospective study of tracheal intubations conducted at a tertiary academic hospital. This analysis included all intubations performed by the medical emergency team in the general ward during a 48-month period.ResultsFor the 958 included patients, the initial laryngoscopy mode was video laryngoscopy in 493 (52%) and direct laryngoscopy in 465 patients (48%). The overall first-attempt success rate was 69% (664 patients). The first-attempt success rate was higher with VL (79%; 391/493) than with DL (59%; 273/465, p < 0.001). The first-attempt intubation success rate was higher among experienced operators (83%; 266/319) than among inexperienced operators (62%; 398/639, p < 0.001). In multivariate logistic regression analyses, VL, pre-intubation heart rate, pre-intubation SpO2 > 80%, a non-predicted difficult airway, experienced operator, and Cormack-Lehane grade were associated with first-attempt intubation success in the general ward. Over all intubation-related complications were not different between two groups (27% for VL vs. 25% for DL). However, incidence of a post-intubation SpO2 < 80% was higher with VL than with DL (4% vs. 1%, p = 0.005), and in-hospital mortality was also higher (53.8% vs. 43%, p = 0.001).ConclusionIn a general ward setting, the first-attempt intubation success rate was higher with video laryngoscopy than with direct laryngoscopy. However, video laryngoscopy did not reduce intubation-related complications. Furthers trials on best way to perform intubation in the emergency settings are required.

Project description:BackgroundData on the routine use of video-assisted laryngoscopy in peri-operative intubations are rather inconsistent and ambiguous, in part due to small populations and non-uniform outcome measures in past trials. Failed or prolonged intubation procedures are a reason for relevant morbidity and mortality. This study aims to determine whether video-assisted laryngoscopy (with both Macintosh-shaped and hyperangulated blades) is at least equal to the standard method of direct laryngoscopy with respect to the first-pass success rate. Furthermore, validated tools from the field of human factors will be applied to examine within-team communication and task load during this critical medical procedure.MethodsIn this randomized, controlled, three-armed parallel group design, multi-centre trial, a total of more than 2500 adult patients scheduled for perioperative endotracheal intubation will be randomized. In equally large arms, video-assisted laryngoscopy with a Macintosh-shaped or a hyperangulated blade will be compared to the standard of care (direct laryngoscopy with Macintosh blade). In a pre-defined hierarchical analysis, we will test the primary outcome for non-inferiority first. If this goal should be met, the design and projected statistical power also allow for subsequent testing for superiority of one of the interventions. Various secondary outcomes will account for patient safety considerations as well as human factors interactions within the provider team and will allow for further exploratory data analysis and hypothesis generation.DiscussionThis randomized controlled trial will provide a solid base of data in a field where reliable evidence is of major clinical importance. With thousands of endotracheal intubations performed every day in operating rooms around the world, every bit of performance improvement translates into increased patient safety and comfort and may eventually prevent significant burden of disease. Therefore, we feel confident that a large trial has the potential to considerably benefit patients and anaesthetists alike.Trial registrationClincalTrials.gov NCT05228288.Protocol version1.1, November 15, 2021.

Project description:ImportanceEndotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear.ObjectiveTo determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.Design, setting, and participantsCluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.InterventionsTwo sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.Main outcomes and measuresThe primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries.ResultsAmong 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).Conclusion and relevanceIn this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.Trial registrationClinicalTrials.gov Identifier: NCT04701762.

Project description:BackgroundA recent large multicentre trial found no difference in clinical outcomes but identified a possibility of increased mortality rates in patients with acute kidney injury (AKI) receiving higher protein. These alarming findings highlighted the urgent need to conduct an updated systematic review and meta-analysis to inform clinical practice.MethodsFrom personal files, citation searching, and three databases searched up to 29-5-2023, we included randomized controlled trials (RCTs) of adult critically ill patients that compared higher vs lower protein delivery with similar energy delivery between groups and reported clinical and/or patient-centred outcomes. We conducted random-effect meta-analyses and subsequently trial sequential analyses (TSA) to control for type-1 and type-2 errors. The main subgroup analysis investigated studies with and without combined early physical rehabilitation intervention. A subgroup analysis of AKI vs no/not known AKI was also conducted.ResultsTwenty-three RCTs (n = 3303) with protein delivery of 1.49 ± 0.48 vs 0.92 ± 0.30 g/kg/d were included. Higher protein delivery was not associated with overall mortality (risk ratio [RR]: 0.99, 95% confidence interval [CI] 0.88-1.11; I2 = 0%; 21 studies; low certainty) and other clinical outcomes. In 2 small studies, higher protein combined with early physical rehabilitation showed a trend towards improved self-reported quality-of-life physical function measurements at day-90 (standardized mean difference 0.40, 95% CI - 0.04 to 0.84; I2 = 30%). In the AKI subgroup, higher protein delivery significantly increased mortality (RR 1.42, 95% CI 1.11-1.82; I2 = 0%; 3 studies; confirmed by TSA with high certainty, and the number needed to harm is 7). Higher protein delivery also significantly increased serum urea (mean difference 2.31 mmol/L, 95% CI 1.64-2.97; I2 = 0%; 7 studies).ConclusionHigher, compared with lower protein delivery, does not appear to affect clinical outcomes in general critically ill patients but may increase mortality rates in patients with AKI. Further investigation of the combined early physical rehabilitation intervention in non-AKI patients is warranted.Prospero idCRD42023441059.

Dataset Information

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

Background

Methods

Results

Conclusion

Publications

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

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