Indirect laryngoscopy is more effective than direct laryngoscopy when tracheal intubation is performed by novice operators: a systematic review, meta-analysis, and trial sequential analysis

Why go blind if you can see the airway?

Airway management is a critical aspect of anesthesiology, essential for ensuring patient safety during various medical interventions, including surgery, emergency care, and critical care settings. Despite advancements, difficult laryngoscopy and tracheal intubation remain significant challenges, particularly in emergency scenarios, posing risks of hypoxia, brain damage, and death. This article examines the efficacy of videolaryngoscopy (VLS) and video laryngeal mask airways (VLMA) in improving airway management outcomes compared to traditional techniques across diverse clinical environments. We conducted a comprehensive review of literature and current practices, analyzing the advantages and limitations of VLS and VLMA. The paper highlights the importance of visualization in airway management and evaluates the effectiveness of these devices in various settings. VLS and VLMA offer several benefits over traditional direct laryngoscopy, including enhanced glottic visualization, higher first-attempt success rates, reduced rates of oxygen desaturation, and fewer adverse events. These devices provide a larger angle of view and allow for real-time monitoring, improving overall patient safety. Additionally, they serve as excellent educational tools for training anesthesiologists and other healthcare providers involved in airway management. In emergency and critical care scenarios, the rapid and accurate placement of airway devices is crucial. VLS and VLMA facilitate quicker and more reliable intubation, reducing the likelihood of complications such as esophageal intubation or airway trauma. These technologies also allow for better teamwork and coordination as the airway view can be shared with the entire medical team. The adoption of VLS and VLMA as standard practice in airway management can significantly enhance visualization and success rates, reducing the risk of complications. These devices should be integrated into routine clinical use to improve patient outcomes. Further research is warranted to optimize their application and explore advancements such as artificial intelligence in airway management.

Evaluation of the Learning Curve of Endotracheal Intubation with Videolaryngoscopes: McGrathMAC, UESCOPE, and Airtraq by Young Anesthesiology Residents - Randomized, Controlled, Blinded Crossover Study

Background

Videolaryngoscopes increased the safety of patients requiring endotracheal intubation. Their particular beneficiaries are healthcare providers inexperienced in intubation. We compared the learning curve of McGrath, UESCOPE, and Airtraq VLs among the first-year anesthesiology residents.

Methods

Sixteen residents were qualified for the study, none of whom has ever before used any VL nor had any experience with the Macintosh laryngoscope. The study was conducted during anesthesia without anticipated intubation difficulties and included 288 adult patients with BMI <25 and ASA ≤ II, without visible intubation difficulties. It was a randomized, controlled, and blinded crossover study. Each resident performed six intubations with a given VL in randomized order.

Results

There were no statistically significant differences in patient characteristics. In McGrath there was observed significant improvement of intubation time, confirmed intubation time, ease, POGO scale, effective intubation, thyroid pressure application, and intubation trauma. Intubation efficacy increased from 12 (75%) at first attempt, to 16 (100%) during third and following attempts. Residents used pressure 6 times (38%) during first attempt and 7 times (44%) during second attempt, and 1 (6%) at last attempt. McGrath traumatism was noticed in 4 (25%) patients at first two attempts, none during third and following attempts. In Airtraq, we observed a significant improvement of intubation time, time of confirmed intubation, force used, ease, effective intubation, and application of pressure to thyroid cartilage. Intubation efficacy increased from 10 (62%) during the first to 16 (100%) during the following attempts. Thyroid pressure was applied 7 times (44%) during first intubation and 0 times during the last two attempts. In the case of UESCOPE VL, we observed a significant improvement of intubation time, time of confirmed intubation, force used, and ease.

Conclusion

Results demonstrated that Airtraq VL having the best learning curve, and UESCOPE having the best first-time use. The results require confirmation in a larger study group. This study was approved on 14 November 2023 by the Medical University of Lodz Bioethics Committee (ref: RNN/160/23/KE).

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024.

STUDY SELECTION

We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945).

DATA SYNTHESIS

We included 20 RCTs ( n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL.

CONCLUSIONS

In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.

Endotracheal Intubation Outside the Operating Room: Year in Review 2023

Endotracheal intubation is a common lifesaving procedure that often is performed outside the operating room in a variety of clinical scenarios. Providers who perform intubation outside the operating room have variable degrees of training, skill development, and experience. A large number of studies were published in 2023 on the topic of intubations outside the operating room across a wide variety of settings and patient populations. Here, we review relevant papers on this topic published in 2023.