Different classes of videoscopes and direct laryngoscopes for double-lumen tube intubation in thoracic surgery: A systematic review and network meta-analysis

Abstract

Background: Double-lumen tube is commonly used in thoracic surgeries that need one-lung ventilation, but its big size and stiff structure make it harder to perform intubation than a conventional tracheal intubation tube.

Objectives: To investigate the effectiveness and safety of videoscopes for double-lumen tube insertion. The primary outcome was the success rate of first attempt intubation. Secondary outcomes were intubation time, malposition, oral mucosal damage, sore throat, and external manipulation.

Design: Systematic review and network meta-analysis.

Data sources: Databases (Pubmed, Embase, Cochrane, Kmbase, Web of science, Scopus) up to June 23, 2020 were searched.

Eligibility: Randomized controlled trials comparing different videoscopes for double-lumen tube intubation were included in this study.

Methods: We classified and lumped the videoscope devices into the following groups: standard (non-channeled) videolaryngoscope, channeled videolaryngoscope, videostylet, and direct laryngoscope. After assessing the quality of evidence, we statistically analyzed and chose the best device based on the surface under the cumulative ranking curve (SUCRA) by using STATA software (version 16).

Results: We included 23 studies (2012 patients). Based on the success rate of the first attempt, a rankogram suggested that the standard videolaryngoscope (76.4 of SUCRA) was the best choice, followed by videostylet (65.5), channeled videolaryngoscope (36.1), and direct laryngoscope (22.1), respectively. However, with regard to reducing the intubation time, the best choice was videostylet, followed by a direct laryngoscope, channeled videolaryngoscope, and standard videolaryngoscope, respectively. Direct laryngoscope showed the lowest incidence of malposition but required external manipulation the most. Channeled videolaryngoscope showed the highest incidence of oral mucosal damage, but showed the lower incidence of sore throat than standard videolaryngoscope or direct laryngoscope.

Conclusion: Most videoscopes improved the success rate of double-lumen tube intubation; however, they were time-consuming (except videostylet) and had a higher malposition rate than the direct laryngoscope.

Fig 1. PRISMA flow diagram.

A total of 23 randomized controlled trials of double-lumen tube intubation with videoscopes were included in this network meta-analysis.

Fig 2. Risk of bias assessments.

Fig 3. Evidence network plots for the outcomes showing the four types of laryngoscopes included in the network meta-analysis.

The size of the nodes corresponds to the total number of studies with each device. The thickness of the lines is proportional to the number of studies making this comparison. (A) The success rate of the first attempt, (B) intubation time, (C) malposition, (D) sore throat, (E) oral mucosal damage, and (F) external manipulation. Mc, Macintosh (direct) laryngoscope; SV, standard non-channeled videolaryngoscope; CV, channeled videolaryngoscope; stylet V, videostylet.

Fig 4. Contribution plot for each direct comparison.

The rows correspond to the mixed and indirect evidence, whereas the columns correspond to the direct evidence. The percentage contribution of each direct comparison to the network summary is presented in the entire network row. The sizes of the boxes are proportional to the percentage contribution of each direct estimate to the network meta-analysis estimates and to the entire network. The last row shows the number of direct comparisons included. (A) The success rate of the first attempt, (B) intubation time, (C) malposition, (D) sore throat, (E) oral mucosal damage, and (F) external manipulation. Mc, Macintosh (direct) laryngoscope; SV, standard non-channeled videolaryngoscope; CV, channeled videolaryngoscope; stylet V, videostylet.

Fig 5. The estimated pair-wise summary effects of outcomes that show the 95% CI and PrI of the estimates and the GRADE score.

A GRADE score was assessed in each comparison. ¹high inconsistency, ²high indirectness, ³high imprecision (wide CI). (A) The success rate of the first attempt, (B) intubation time, (C) malposition, (D) sore throat, (E) oral mucosal damage, and (F) external manipulation. Mc, Macintosh (direct) laryngoscope; SV, standard non-channeled videolaryngoscope; CV, channeled videolaryngoscope; stylet V, videostylet.

Fig 6. The cumulative ranking curve of the outcomes of the different laryngoscopes.

The surface under the cumulative ranking curve (SUCRA) represents the ranking of devices. A higher SUCRA suggests a higher probability of being a good device. (A) The success rate of the first attempt, (B) intubation time, (C) malposition, (D) sore throat, (E) oral mucosal damage, and (F) external manipulation. Mc, Macintosh (direct) laryngoscope; SV, standard non-channeled videolaryngoscope; CV, channeled videolaryngoscope; stylet V, videostylet.