Comparison of Video Laryngoscopy Versus Direct Laryngoscopy During
Urgent Endotracheal Intubation: A Randomized Controlled Trial*
Critical Care Medicine
Issue: Volume 43(3), March 2015, p 636641
Main questions asked and a brief summary:
Emergency intubation is always a stressful scenario for all. This often is
associated with additional difficulty in obtaining good view of the vocal cord and
complications like hypoxia, hypotension, airway trauma and even cardiac arrest.
This study sought to find the answer if video laryngoscopy (VL)is superior in
urgent tracheal intubation to direct laryngoscopy (DL) in ICU environment or in
other emergencies in medical wards. The results showed overwhelming
difference between the DL and VL group in terms of first attempt success.
Study design:
Setting:
Beth Israel Medical Center, an 856-bed urban teaching hospital with a 16-bed
closed medical ICU and medical wards keeping acutely ill patients.
Patients:
Inclusion criteria: All patients requiring intubation in the medical ICU or the
wards by pulmonary/ critical care medicine fellows.
Exclusion criteria: If the intubation was elective, limited mouth opening/
oropharyngeal masses/ swollen tongue, SpO2< 92% after bag-valve mask
ventilation. Cardiac arrest patients were not excluded.
Intervention and methods:
Personnel: There were 8 critical care medicine fellows, who responded as first
intubator. They received about 10 sessions, one hour each, of training around
airway management including team working . They practiced on simulated
computer based scenarios before being tested for competency. They then were
allowed to act as first responders in medical emergencies as part of critical care/
intubation team. Neuromuscular blockade was not routinely used. A rigid stylet
was used for all VL intubation. Usually there were an anaesthesiologist or ICU
consultant present supervising the intubation process.
A resident was allocated the role for real time data collection.
Statistics:
Patients were randomised to either DL or VL guided guided intubation through
odd and even number randomisation. Based on an assumption of 15%
improvement with video laryngoscope, a sample size of 139 was calculated to
provide a power of 90% to identify a significant statistical difference in the
primary outcome. The study was stopped at mid-point review for safety as the
first attempt success was much higher in the video laryngoscopy group.
Results:
Data from 117 were analysed after 36 from 153 consecutive intubations were
excluded during study period. 57 were randomized to the GVL group and 60 to
the DL group.
In DL and VL groups, mean body weight were 68 and 66 kg and BMI were 25 and
23 respectively. Patients were critically ill with APACHE II scoe of 21 and 20
respectively in DL and VL groups. The only significant difference was in the rate
of malignancy (27% in DL and 9% in VL group).
The salient points regarding results of the intubation process are :
The fellows successfully intubated all but 2 patients.
The rate of first-attempt success in the GVL group was 74%
compared with 40% in the DL group (p < 0.01).
Twenty-seven percent in the DL group required more than two attempts
compared with 9% requiring more than two attempts in the GVL group
(p < 0.01).
82% of all patients who could not be intubated with DL, could be intubated
with VL on first attempt.
The time to intubation was 218 seconds in the DL group and 120 seconds
in the VL group (p < 0.01).
The time to intubation was similar in the groups when only one attempt
was necessary.
The average number of attempts was 1.93 in the DL group versus 1.39 in
the GVL group (95% CI, 0.230.86; p < 0.01).
All oesophageal intubations were in the DL group.
Cormack-Lehane grade 1 or 2 intubations were 57% and 93% respectively
in the DL and VL groups
All intubations were performed with direct endotracheal tube placement,
and a bougie was not used.
No significant difference between groups in complications
Five patients with a recognized difficult airway were all intubated
successfully with the GVL on the first attempt.
17 patients excluded for desaturation, 14 were intubated with the VL on
the first attempt and one on the second attempt. Two patients were
intubated with the DL, one requiring two attempts.
Conclusion by the authors:
VL showed improved glottis view and first attempt success. The lower success
rate with DL should prompt further studies on the effect of VL on DL skill
acquisition.
My take:
Strength of the study and applicability in a UK hospital:
Randomised controlled design
Data were collected prospectively by an independent observer in real
time, removing both operator and recall bias.
Equal training on each device was provided prior to the study.
Odd-even randomisation strategy ensured avoidance of delay
Sickness level of the patients would probably reflect the sickness of
patients at similar scenarios in a standard UK DGH
Weaknesses of the study:
The study personnel do not match the UK first responder intubators widely
in their skillset and training methods
NO RSI, No muscle relaxant used during intubation
Single centre involving work and skill set of only 8 fellows
Lower than usual first attempt success rate in the DL group due to skill
level or is it due to the availability of the VL as a fall-back option that
reduced the intensity of manipulation with DL before giving up premarely?
Only one type of VL was used, therefore the results may not be
generalisable
No mention of how the fellows maintain their skill
Although this study did not show any difference in complication, usually a
delay and more no of attempts in intubation lead to complications.
Final words:
Because of the variance in practice compared with the standard UK
procedures for emergency intubation, many would be sceptical about
implementing video laryngoscopy widely on the basis of the findings of this
study. Especially one would be concerned about the low success rate at first
attempts in this study, which may be related to the non-use of muscle relaxants.
The personnel were from a medical, and not anaesthesia, background. Therefore
the teams, which increasingly have trainees from medical backgrounds, may
think of using VLs as first intubating techniques. On the other hand, teams
consisting of anaesthetists do not have immediate pressing need to embrace this
just yet and can still keep VL as part of their difficult airway trolley.
However, in the days of increasing drive for patient safety, one would argue, why
not incorporate something which clearly increases chance of success in an
emergency (there are data available from other observational studies in support
of this). So my vote will go for incorporating VL as the initial instrument in the
emergency intubation scenario.
