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VL vs DL in the Operating Room

May 31, 2024

Written by Jason Lesnick

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This single site RCT found that for patients undergoing intubation for mainly elective surgeries, hyperangulated video-laryngoscopy (VL) had higher first-pass success and lower rates of intubation failure compared to Mac direct laryngoscopy (DL).

Still beating the direct horse?
This was a cluster randomized controlled trial comparing initial intubation attempt with hyperangulated VL (Glidescope used here) to Mac DL from March 2021 to December 2022 at a single US academic hospital. 8,429 surgeries requiring intubation occurred, with cluster randomization being done weekly with two sets of eleven operating rooms.

15,796 surgeries were screened, 7,367 excluded, and 8,429 surgeries remained across 7,736 patients with a median age of 66, 35% female, and 85% of surgeries were elective. Patients were excluded if they were already intubated, did not need intubation, required a double lumen tube, needed awake fiberoptic intubation, and in those whom clinicians refused to participate.

The primary outcome was the number of intubation attempts per surgical procedure while secondary outcomes included intubation failure (defined as switching to alternative laryngoscopy device or more than 3 intubation attempts) and a composite of airway/dental injuries.

The authors found with hyperangulated VL the first-pass success rate was 98.3% compared to 92.4% with DL, proportional odds ratio 0.2 (95%CI 0.14-0.28) – that’s an 80% higher odds of fewer intubation attempts with VL over DL. Intubation failure occurred in 0.27% of VL attempts (12/4,413) compared to 4.0% of DL (161/4,016; RR 0.06, 95%CI, 0.03-0.14, P < 0.001). There was not a significant difference between airway/dental injuries by device used (0.93% VL, 1.1% DL). The trial was stopped early at ~50% of max expected enrollment after the second interim analysis.

Interestingly, of the 8,429 intubations, 3,283 (38.9%) were performed by nurse anesthetists, 2,514 (29.8%) by residents, 1,185 (14.1%) by fellows, 1,175 (13.9%) by student nurse anesthetists, 225 (2.7%) by attending anesthesiologists, and 47 (0.6%) by medical students.

How will this change my practice?
This study won’t affect my practice much – I will continue to use the hyperangulated blade in specific scenarios (i.e. anterior airways) and strongly prefer VL as my first-line intubation technique, as the body of evidence continues to grow supporting VL over DL.

Editor’s note: Though not directly generalizable to the ED, there is increasing evidence for the superiority of VL, in its various forms, in multiple practice settings. These were experienced clinicians, which would tend to skew results toward the null, yet we still see that even hyperangulated VL was better. ~Clay Smith

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024 Mar 18:e240762. doi: 10.1001/jama.2024.0762. Epub ahead of print. PMID: 38497992.

What are your thoughts?