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Has VL Finally Won? VL vs. Augmented DL

February 4, 2020

Written by Aaron Lacy

Spoon Feed
Unaided video laryngoscopy (VL) alone had a higher first-pass success rate when compared to direct laryngoscopy (DL) with either ramped positioning, use of external laryngeal manipulation (ELM), bougie or some combination thereof.

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. So, is VL really better or not?

Should VL be best practice?
This secondary-analysis of NEAR data was an attempt to specifically address a comparison of unaided hyperangulated blade (HA) or standard geometry blade (SG) VL to DL with optimization including ramped positioning, ELM, and use of a bougie (augmented DL, or, A-DL). Over a 2-year period, comparison of 3,936 A-DL versus 3,002 unaided VL intubations showed statistically significant higher first-pass success rate in VL (90.9%, 95% CI 88.7-93.1) versus A-DL in all cases (81.1%, 95% CI 78.7-83.5).

Multivariable regression analyses showed any type of unaided HA-VL or SG-VL had higher likelihood of first-attempt success rate compared to any specific combination of A-DL. Fewer esophageal intubations were observed in the VL cohort (0.4% vs 1.3%, AOR = 0.2, 95% CI 0.1 – 0.5). While learning and maintaining DL skills are crucial, as VL capabilities are not ubiquitous and technology can fail, this study further strengthens the case of those who argue for VL vs. DL as standard of care in endotracheal intubation.

Another Spoonful
Here is a link to an audio interview with the lead author Dr. Calvin Brown III.

Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study. . Acad Emerg Med. 2020 Jan 20. doi: 10.1111/acem.13851. [Epub ahead of print]

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