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Meta-Analysis
. 2018 Jun 4;6(6):CD009975.
doi: 10.1002/14651858.CD009975.pub3.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

Krithika Lingappan  1 , Jennifer L Arnold, Caraciolo J Fernandes, Mohan Pammi
Affiliations
Meta-Analysis

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

Krithika Lingappan et al. Cochrane Database Syst Rev. .

Update in

Abstract

Background: Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

Objectives: To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates.

Search methods: We used the search strategy of Cochrane Neonatal. In May 2017, we searched for randomized controlled trials (RCT) evaluating videolaryngoscopy for neonatal endotracheal intubation in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, abstracts of the Pediatric Academic Societies, websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com, and reference lists of relevant studies.

Selection criteria: RCTs or quasi-RCTs in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

Data collection and analysis: Review authors performed data collection and analysis as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.We used the GRADE approach to assess the quality of evidence.

Main results: The search yielded 7057 references of which we identified three RCTs for inclusion, four ongoing trials and one study awaiting classification. All three included RCTs compared videolaryngoscopy with direct laryngoscopy during intubation attempts by trainees.Time to intubation was similar between videolaryngoscopy and direct laryngoscopy (mean difference (MD) -0.62, 95% confidence interval (CI) -6.50 to 5.26; 2 studies; 311 intubations) (very low quality evidence). Videolaryngoscopy did not decrease the number of intubation attempts (MD -0.05, 95% CI -0.18 to 0.07; 2 studies; 427 intubations) (very low quality evidence). Moderate quality evidence suggested that videolaryngoscopy increased the success of intubation at first attempt (typical risk ratio (RR) 1.44, 95% CI 1.20 to 1.73; typical risk difference (RD) 0.19, 95% CI 0.10 to 0.28; number needed to treat for an additional beneficial outcome (NNTB) 5, 95% CI 4 to 10; 3 studies; 467 intubation attempts).Desaturation episodes during intubation attempts were similar between videolaryngoscopy and direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations) (low quality evidence). There was no difference in the incidence of airway trauma due to intubation attempts (RR 0.10, 95% CI 0.01 to 1.80; RD -0.04, 95% CI -0.09 to -0.00; 1 study; 213 intubations) (low quality evidence).There were no data available on other adverse effects of videolaryngoscopy.

Authors' conclusions: Moderate to very low quality evidence suggests that videolaryngoscopy increases the success of intubation in the first attempt but does not decrease the time to intubation or the number of attempts for intubation. However, these studies were conducted with trainees performing the intubations and these results highlight the potential usefulness of the videolaryngoscopy as a teaching tool. Well-designed, adequately powered RCTs are necessary to confirm efficacy and address safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates by trainees and those proficient in direct laryngoscopy.

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Conflict of interest statement

KL: no conflicts of interest.

JA: no conflicts of interest.

TS: no conflicts of interest.

CF: no conflicts of interest.

MP: no conflicts of interest.

Figures

Figure 1
Figure 1
Study flow diagram: review update.
Figure 2
Figure 2
Forest plot of comparison: 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), outcome: 1.1 Time required for successful intubation (seconds).
Figure 3
Figure 3
Forest plot of comparison: 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), outcome: 1.2 Number of intubation attempts.
Figure 4
Figure 4
Forest plot of comparison: 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), outcome: 1.3 Success rate at first attempt.
Analysis 1.1
Analysis 1.1
Comparison 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 1 Time required for successful intubation (seconds).
Analysis 1.2
Analysis 1.2
Comparison 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 2 Number of intubation attempts.
Analysis 1.3
Analysis 1.3
Comparison 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 3 Success rate at first attempt.
Analysis 1.4
Analysis 1.4
Comparison 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 4 Non‐airway related adverse effects: saturations during intubation.
Analysis 1.5
Analysis 1.5
Comparison 1 Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 5 Airway‐related adverse effects: airway trauma.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

    1. Moussa A, Luangxay Y, Tremblay S, Lavoie J, Aube G, Savoie E, et al. Videolaryngoscope for teaching neonatal endotracheal intubation: a randomized controlled trial. Pediatrics 2016;137(3):e20152156. [DOI: 10.1542/peds.2015-2156; PUBMED: 26908701] - DOI - PubMed
    1. O'Shea JE, Thio M, Kamlin CO, McGrory L, Wong C, John J, et al. Videolaryngoscopy to teach neonatal intubation: a randomized trial. Pediatrics 2015;136(5):912‐9. [DOI: 10.1542/peds.2015-1028; PUBMED: 26482669] - DOI - PubMed
    1. Volz S, Stevens TP, Dadiz R. A randomized controlled trial: does guidance using video laryngoscopy improve residents' success in neonatal intubations?. Pediatrics Academic Societies Annual Meeting; 2016 30 Apr‐3 May 2016; Baltimore (MD). 2016.

References to studies excluded from this review

    1. Fiadjoe JE, Gurnaney H, Dalesio N, Sussman E, Zhao H, Zang X, et al. A prospective randomized equivalence trial of the GlideScope Cobalt video laryngoscope to traditional direct laryngoscopy in neonates and infants. Anesthesiology 2012;116(3):622‐8. [DOI: 10.1097/ALN.0b013e318246ea4d; PUBMED: 22270505] - DOI - PubMed
    1. Komasawa N, Hattori K, Mihara R, Minami T. Direct laryngoscopy training is important for videolaryngoscopy skill acquisition. British Journal of Anaesthesia 2017;118(2):269‐70. [DOI: 10.1093/bja/aew458; PUBMED: 28100534] - DOI - PubMed
    1. Parmekar S, Arnold JL, Anselmo C, Pammi M, Hagan J, Fernandes CJ, et al. Mind the gap: can videolaryngoscopy bridge the competency gap in neonatal endotracheal intubation among pediatric trainees? A randomized controlled study. Journal of Perinatology 2017;37(8):979‐83. [DOI: 10.1038/jp.2017.72; PUBMED: 28518132] - DOI - PubMed
    1. Sørensen M, Holm‐Knudsen R. Endotracheal intubation with Airtraq® versus Storz® videolaryngoscope in children younger than two years ‐ a randomized pilot‐study. BMC Anesthesiology 2012;12:7. [DOI: 10.1186/1471-2253-12-7; PUBMED: 22545575] - DOI - PMC - PubMed
    1. Vlatten A, Aucoin S, Litz S, Macmanus B, Soder C. A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway ‐ a randomized clinical trial. Paediatric Anaesthesia 2009;19(11):1102‐7. [DOI: 10.1111/j.1460-9592.2009.03127.x; PUBMED: 19708910] - DOI - PubMed

References to studies awaiting assessment

    1. Singh R, Singh P, Vajifdar H. A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants. Paediatric Anaesthesia 2009;19(4):338‐42. [DOI: 10.1111/j.1460-9592.2009.02929.x; PUBMED: 19335346] - DOI - PubMed

References to ongoing studies

    1. Bellhouse S. A randomised controlled clinical trial comparing C‐MAC (Trademark) videolaryngoscope intubation with direct laryngoscope intubation in neonates. The HEADS UP Study. www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367096 Date first received: 24 October 2014.
    1. NCT01371032. Study to compare video miller device to direct laryngoscopy [A randomized, prospective study to compare the video miller device to direct laryngoscopy using a standard pediatric Miller Blade for tracheal intubation of children < 3 years of age undergoing general anesthesia]. clinicaltrials.gov/show/NCT01371032 Date first received: 10 June 2011.
    1. NCT01793727. Infant Glidescope® learning curve. clinicaltrials.gov/show/NCT01793727 Date first received: 15 February 2013.
    1. Fiadjoe 2018. The Videolaryngoscopy in Small Infants (VISI). clinicaltrials.gov/ct2/show/NCT03396432 Date first registered: 11 January 2018.

Additional references

    1. Asai T, Enomoto Y, Shimizu K, Shingu K, Okuda Y. The Pentax‐AWS video‐laryngoscope: the first experience in one hundred patients. Anesthesia and Analgesia 2008;106(1):257‐9. [DOI: 10.1213/01.ane.0000287647.46165.bc; PUBMED: 18165587] - DOI - PubMed
    1. Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C‐MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology 2012;116(3):629‐36. [DOI: 10.1097/ALN.0b013e318246ea34; PUBMED: 22261795] - DOI - PubMed
    1. Choong K, AlFaleh K, Doucette J, Gray S, Rich B, Verhey L, et al. Remifentanil for endotracheal intubation in neonates: a randomised controlled trial. Archives of Disease in Childhood. Fetal and Neonatal Edition 2010;95(2):F80‐4. [DOI: 10.1136/adc.2009.167338; PUBMED: 20231228] - DOI - PubMed
    1. Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics 2003;112(6 Pt 1):1242‐7. [PUBMED: 14654592] - PubMed
    1. Feltman DM, Weiss MG, Nicoski P, Sinacore J. Rocuronium for nonemergent intubation of term and preterm infants. Journal of Perinatology 2011;31(1):38‐43. [DOI: 10.1038/jp.2010.74; PUBMED: 20539274] - DOI - PubMed

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