Video equals direct laryngoscope?

July 12, 2016

Short Attention Span Summary

This is another study by the FELLOW investigators.  You may recall the recent FELLOW trial regarding apneic oxygenation.  This study looked at video (VL) vs. direct laryngoscopy (DL) and first-pass success in the ICU.  This was a randomized controlled trial of adult ICU patients.  VL provided better glottic visualization than DL but the same first-pass success rate, around 66-69%.  Other secondary outcomes were also not different.  Anecdotally, my sense is that this first-pass success rate is poor and is far less than the success rate I see in the ED.  This is, in fact, correct.  Success was lower than in this trial than the ED first-pass success rate of 83-86%.  See this article by Ron Walls and colleagues about a year ago.  It does not make sense to me that if you can see the glottic opening better, you can’t intubate better.  Granted, use of a hyperacute angle blade, like the GlideScope forces the operator to curve the stylet more.  And the tube will not pass, even when through the cords, unless the stylet is withdrawn slightly.  Maybe that was the issue.  In this study, intubators could choose between the McGrath, GlideScope, or Olympus Video Bronchoscope.  Why they didn’t use a Storz C-MAC is baffling to me.  The future is VL and many studies have shown far superior intubating conditions using VL.  This study doesn’t shake me from that conclusion.

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FOAM Report

• Virtual Journal Club
• Airway Jedi discusses problems that may occur (not specifically in this trial), like a highly bent stylet

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Abstract

Crit Care Med. 2016 Jun 28. [Epub ahead of print]

Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults.

Janz DR1, Semler MW, Lentz RJ, Matthews DT, Assad TR, Norman BC, Keriwala RD, Ferrell BA, Noto MJ, Shaver CM, Richmond BW, Zinggeler Berg J, Rice TW; Facilitating EndotracheaL intubation by Laryngoscopy technique and apneic Oxygenation Within the ICU Investigators and the Pragmatic Critical Care Research Group.

Author information:

11Department of Medicine, Section of Pulmonary and Critical Care Medicine Louisiana State University School of Medicine, New Orleans, LA. 2Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN.

Abstract

OBJECTIVE:

To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

DESIGN:

A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

SETTING:

Medical ICU in a tertiary, academic medical center.

PATIENTS:

Critically ill patients 18 years old or older.

INTERVENTIONS:

Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS:

Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator’s previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

CONCLUSIONS:

In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

PMID: 27355526 [PubMed – as supplied by publisher]