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Which Is Better – VL or DL?

November 5, 2018

Written by Clay Smith

Spoon Feed
Video laryngoscopy (VL) gets the green light from Academic Emergency Medicine over direct laryngoscopy (DL) – clear benefit, no harm. For every 17 intubations using VL, one less patient will have a failed intubation.

Why does this matter?
The FELLOW, MACMAN, ED-based RCT, and dubious meta-analysis all found that VL did not improve first pass success over DL. Yet a Cochrane review in 2016 found VL had big advantages. AEM summarized that review.

Levitan says don’t choose VL or DL – use one that does both
This was a meta-analysis of 7044 patients in 64 RCTs, only 3 of which were based in the ED. Use of VL vs DL reduced the number of failed intubations. In the original study, the absolute risk of failed airway was 9.4% with DL, 3.5% with VL; ARR = 0.094 – 0.035 = 0.059; 1/ARR = NNT = 17. For every 17 intubations, this means one less failed intubation. That’s a big deal. Authors said the NNT was 14 (not sure why the difference). Odds of an easy view of the glottic opening were 677% greater for VL over DL (OR 6.77, 95%CI 4.17-10.98). Odds of having no glottic view were reduced by 82% with VL (OR 0.18, 95%CI 0.13-0.27). There was heterogeneity among the RCTs, with 9 VL devices used.  In subgroup analysis, the Storz C-MAC reduced failed intubation more than other VL devices.  They did not find harm associated with VL.  The downsides – most intubations were were performed by anesthesiologists in the OR, not the ED, and device use could not be blinded.  VL devices excelled especially in patients with known or predicted difficult airway. In a 2015 study, 93% of difficult airways were unanticipated. In the ED, we anticipate 100% of our patients will have a difficult airway.  Why would we not give ourselves and our patients every advantage in such a critical procedure?

Another Spoonful

Video Laryngoscopy vs. Direct Laryngoscopy.  Acad Emerg Med. 2018 Oct 15. doi: 10.1111/acem.13627. [Epub ahead of print]

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What are your thoughts?