Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults

Abstract

Objective: To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

Design: A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

Setting: Medical ICU in a tertiary, academic medical center.

Patients: Critically ill patients 18 years old or older.

Interventions: Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

Measurements and main results: Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

Conclusions: In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Figure 1. Patient Screening, Randomization, and Follow-up

Figure 2. Cormack-Lehane Glottic Views Obtained on the First Laryngoscopy Attempt

Video laryngoscopy results in better glottic views during the first laryngoscopy attempt compared with direct laryngoscopy (p = 0.001, Chi-square for a trend).

Figure 3. Subgroup Analyses and Evaluation for Effect Modification

Subgroup analyses were conducted by patient, procedure, and operator-specific variables. Odds ratios and 95% confidence intervals for the outcome of intubation on first attempt using video laryngoscopy are displayed for the overall study at the top of the figure followed by all subgroups. * Adjusted Device Experience represents the primary outcome for reference. The right justified columns are P-values for interaction terms entered into the logistic regression model to test for effect modification of any of the subgroup variables. There were no patient- or procedure-specific subgroups that benefitted from intubation with video laryngoscopy nor were there any statistically significant interactions detected. Regarding the operator specific variables of previous experience with the assigned intubating device, previous total intubating experience, and previous fellowship training experience, operators less experienced with the assigned device (< 30 previous uses of the device, median) and the intubation procedure (< 50 total intubations, lowest quartile of experience) had a higher odds of intubation on first attempt with video laryngoscopy. However, only previous total intubating experience (< 50 total intubations) modified the effect of video laryngoscopy on intubation on first attempt (p = 0.031).