NEJM
June 16, 2023
Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults
Mazen Kherallah
Summarized by:
What was the research question (PICO)?
Population: Critically ill adults undergoing tracheal intubation in an emergency department or ICU.
Intervention: Video laryngoscopy for tracheal intubation.
Comparison: Direct laryngoscopy for tracheal intubation.
Outcome: The primary outcome was successful intubation on the first attempt, and the secondary outcome was the occurrence of severe complications during intubation.
How did they do it?
The trial was a multicenter, randomized study conducted at 17 emergency departments and ICUs.
Critically ill adults undergoing tracheal intubation were randomly assigned to either the video-laryngoscope group or the direct-laryngoscope group.
The primary outcome was successful intubation on the first attempt, and the secondary outcome was the occurrence of severe complications during intubation.
The trial was stopped for efficacy at the time of the single preplanned interim analysis.
A total of 1417 patients were included in the final analysis, with 91.5% of them undergoing intubation performed by an emergency medicine resident or a critical care fellow.
What did they find?
The use of a video laryngoscope resulted in a significantly higher incidence of successful intubation on the first attempt compared to direct laryngoscopy in critically ill adults undergoing tracheal intubation. Successful intubation occurred in 85.1% of patients in the video laryngoscopy group, compared to 70.8% in the direct layngoscopy group. Absolute risk difference between the two groups for successful intubation on the first attempt was 14.3 percentage points (95% CI, 9.9 to 18.7; P<0.001).
The occurrence of severe complications during intubation was similar between the two groups.
Any limitations of the study?
The study does not provide specific recommendations on which brand of video laryngoscope or blade shape leads to the best outcomes.
The findings may not apply to operators with more experience, as 97% of the operators had performed fewer than 250 previous tracheal intubations.
All the intubations occurred in an emergency department or ICU, limiting the generalization of the findings to the operating room.
Patients, clinicians, and trial personnel were aware of the trial-group assignments, potentially introducing bias.
What does it mean?
The use of video laryngoscopy for tracheal intubation resulted in a significantly higher incidence of successful intubation on the first attempt than direct laryngoscopy in critically ill adults in an emergency department or ICU.
This finding has important clinical implications, as failure to intubate on the first attempt is associated with life-threatening complications.
The study supports the increased use of video laryngoscopy in critical care settings, especially for less experienced operators who may benefit from improved laryngeal visualization.
The trial's strengths include randomization, concealment of trial-group assignment, and data collection by an independent observer. However, it also has limitations that should be considered when interpreting the results.
Overall, the findings of this trial suggest that video laryngoscopy can be a valuable tool for improving first-attempt intubation success in critically ill patients in the emergency department and ICU.