Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting.

METHODS

We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD =  - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD =  - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05).

CONCLUSION

In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.

Evaluation of preintubation shock index and modified shock index as predictors of postintubation hypotension and other short-term outcomes

PURPOSE

Preintubation shock index (SI) and modified shock index (MSI) have demonstrated predictive capability for postintubation hypotension in emergency department. The primary aim was to explore this relationship in the critical care environment. The secondary aims were to evaluate the relationship of shock indices with other short-term outcomes like mortality and length of stay in intensive care unit.

MATERIALS AND METHODS

This is a nonconcurrent cohort study, conducted in eligible 140 adult intensive care unit (ICU) patients of a tertiary care medical center. Eligibility criterion was emergent endotracheal intubation in apparently hemodynamically stable patients.

RESULTS

Preintubation SI ≥ 0.90 had a significant association with postintubation hypotension as defined by systolic blood pressure < 90 mm Hg in the univariate (P = .03; odds ratio [OR], 2.13; 95% confidence interval [CI], 1.07-4.35) and multivariate analyses (P = .01; OR, 3.17; 95% CI, 1.36-7.73) after adjusting for confounders. It was also associated with higher ICU mortality in both the univariate (P = .01; OR, 4.00; 95% CI, 1.26-12.67) and multivariate analyses (P = .01; OR, 5.75; 95% CI, 1.58-26.48). There was no association of preintubation MSI with postintubation hemodynamic instability and ICU mortality. No association was found between preintubation SI and MSI, with ICU length of stay and 30-day mortality.

CONCLUSIONS

Our findings indicate that preintubation SI greater than or equal to 0.90 is a predictor of postintubation hypotension (systolic blood pressure <90 mm Hg) and ICU mortality in emergently intubated adult patients in intensive care units.