Comparison of four channelled videolaryngoscopes to Macintosh laryngoscope for simulated intubation of critically ill patients: the randomized MACMAN2 trial

Training approaches and devices utilization during endotracheal intubation in French Emergency Departments: a nationwide survey

BACKGROUND AND IMPORTANCE

Endotracheal intubation is a lifesaving procedure that is reportedly associated to a significant risk of adverse events. Recent trials have reported that the use of videolaryngoscope and of a stylet might limit this risk during emergency intubation.

OBJECTIVES

The objective of this study was to provide a national description of intubation practices in French Emergency Departments (EDs).

SETTINGS AND PARTICIPANTS

We conducted an online nationwide survey by sending an anonymous 37-item questionnaire via e-mail to 629 physicians in French EDs between 2020 and 2022.

INTERVENTION

A single questionnaire was sent to a sole referent physician in each ED.

OUTCOME MEASURES AND ANALYSIS

The primary endpoint was to assess the proportion of French EDs in which videolaryngoscopy was available for emergency intubation and its use in routine practice. Secondary endpoints included the presence of local protocol or standard of procedure for intubation, availability of capnography, and routine use of a stylet.

MAIN RESULTS

Of the surveyed EDs, 342 (54.4%) returned the completed questionnaire. A videolaryngoscope was available in 193 (56%) EDs, and direct laryngoscopy without a stylet was majorly used as the primary approach in 280 (82%) EDs. Among the participating EDs, 74% had an established protocol for intubation and 92% provided a capnography device for routine verification of tube position. In cases of difficult intubation, the use of a bougie was recommended in 227 (81%) EDs, and a switch to a videolaryngoscope in 16 (6%) EDs. The most frequently used videolaryngoscope models were McGrath Mac Airtraq (51%), followed by Airtraq (41%), and Glidescope (14%).

CONCLUSION

In this large French survey, the majority of EDs recommended direct laryngoscopy without stylet, with seldom use of videolaryngoscopy.

Clinically Preferred Videolaryngoscopes in Airway Management: An Updated Systematic Review

Videolaryngoscopes (VLs) have emerged as a safety net offering several advantages over direct laryngoscopy (DL). The aim of this study is to expand on our previous study conducted in 2016, to deduce which VL is most preferred by clinicians and to highlight any changes that may have occurred over the past 7 years. An extensive systematic literature review was performed on Medline, Embase, Web of Science, and Cochrane Central Database of Controlled Studies for articles published between September 2016 and January 2023. This review highlighted similar results to our study in 2016, with the CMAC being the most preferred for non-channelled laryngoscopes, closely followed by the GlideScope. For channelled videolaryngoscopes, the Pentax AWS was the most clinically preferred. This review also highlighted that there are minimal studies that compare the most-used VLs, and thus we suggest that future studies directly compare the most-used and -preferred VLs as well as the specific nature of blades to attain more useful results.

A test prototype of a novel flexible video laryngoscope and preliminary verification in a difficult airway management simulator

Background

To verify a test prototype of a novel flexible video laryngoscope in a difficult airway management simulator and to compare the efficacy of the flexible video laryngoscope with that of a conventional video laryngoscope.

Methods

Fifteen clinical anesthesiologists performed endotracheal intubation with a flexible video laryngoscope and a conventional video laryngoscope in a difficult airway management simulator in the neutral position with intermediate and difficult mouth opening. The rate of intubation success, intubation time, and classification of glottic exposure were recorded. After endotracheal intubation, participants were asked to assess the difficulty of intubation of the two laryngoscopes.

Results

The success rate of endotracheal intubation with flexible video laryngoscope was significantly higher than that with video laryngoscope in neutral positions with both intermediate (P = 0.025) and difficult (P = 0.005) mouth opening. The Cormack Lehane score of the flexible video laryngoscope was significantly lower than that of the video laryngoscope in the neutral position with intermediate mouth opening (P < 0.001) and difficult mouth opening (P < 0.001). There was no significant difference in intubation time in the neutral position with intermediate mouth opening (P = 0.460) or difficult mouth opening (P = 0.078). The difficulty score of endotracheal intubations with the flexible video laryngoscope was also significantly lower than that of the video laryngoscope in the neutral position with intermediate mouth opening (P = 0.001) and difficult mouth opening (P = 0.001).

Conclusions

Compared with conventional video laryngoscopy, flexible video laryngoscopy can provide superior glottic exposure and improve the success rate of intubation in a difficult airway management simulator.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12938-022-01043-1.

Video Versus Direct Laryngoscopy in Novice Intubators: A Systematic Review and Meta-Analysis

Video laryngoscopy (VL) is increasingly used in airway management and has been shown to decrease the rate of failed intubation in certain clinical scenarios, such as difficult airways. Training novices in intubation techniques requires them to practice on living patients; however, this is less than ideal from a safety perspective given the increased risk of complications after multiple attempts or failed intubation by inexperienced trainees. One setting in which VL may be beneficial is in training, although whether these devices should be used among novices instead of direct laryngoscopy (DL) remains unclear. The purpose of this systematic review and meta-analysis is to compare the outcomes of VL and DL when used by novices to perform intubation in the operating room. The secondary aims are to correlate outcomes with different types of VLs and with different types of novices, such as medical students, residents, and non-anesthesiology trainees.

Databases were searched for studies that compared the outcomes of VL versus DL in endotracheal intubation performed by novices on patients with expected normal airways and no history of difficult intubation or cervical spine instability undergoing general anesthesia in the operating room. The primary outcome was the initial success rate. The secondary outcomes were time to intubate and the number of unintended esophageal intubations. A meta-analysis was performed to determine the difference, if any, in outcomes between VL and DL. Sub-analyses were also performed after the stratification of data by the type of VL used and the type of novice.

Ten studies were included with 1,730 intubations. Studies varied by VL type and novice type. The overall results from the meta-analysis demonstrated an increased success rate and decreased time to intubate with VL compared to DL. Four studies showed a reduction in esophageal intubation with VL compared to DL. Sub-analysis by VL type showed that improved outcomes with VL over DL were maintained only with the use of channeled VLs rather than non-channeled VLs. Sub-analysis by novice type showed that improved success rates with VL over DL were maintained only among medical students.

Novices may have a higher initial success rate and faster intubation time when using a channeled VL compared to DL. Medical students also show improved success rates when using VL rather than DL, while residents and other types of novices do not. These findings may help guide clinicians in determining the most effective devices to use when teaching airway management while also maintaining the highest possible level of patient safety.