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Review
. 2023 May 12;5(5):CD009975.
doi: 10.1002/14651858.CD009975.pub4.

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

Affiliations
Review

Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

Krithika Lingappan et al. Cochrane Database Syst Rev. .

Abstract

Background: Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018.

Objectives: To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age).

Search methods: In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www.

Clinicaltrials: gov; www.controlled-trials.com), and reference lists of relevant studies.

Selection criteria: Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy.

Data collection and analysis: Three 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 certainty of the evidence.

Main results: The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification. Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies. For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence). For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence). There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies.

Authors' conclusions: Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence). These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.

Trial registration: ClinicalTrials.gov NCT01090726 NCT01371032.

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Conflict of interest statement

  1. KL: works as a health professional in Neonatology at Children's Hospital of Philadelphia, USA

  2. NN: works as a health professional in Neonatology at Baylor College of Medicine/Texas Children's Hospital, USA

  3. JA: works as a health professional in Neonatology at Boston Children’s Hospital, USA

  4. CF: works as a health professional in Neonatology at Texas Children's Hospital, USA

  5. MP: works as a health professional in Neonatology at Baylor College of Medicine/Texas Children's Hospital, USA; he is an Associate Editor for Cochrane Neonatal, however, he was not involved in the editorial process for this review

Figures

1
1
PRISMA flow diagram depicting the study selection process
2
2
Risk of bias graph: review authors' judgments about each risk of bias item, presented as percentages across all included studies
3
3
Risk of bias summary: review authors' judgments about each risk of bias item for each included study
1.1
1.1. Analysis
Comparison 1: Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 1: Time required for successful intubation (seconds)
1.2
1.2. Analysis
Comparison 1: Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 2: Number of intubation attempts
1.3
1.3. Analysis
Comparison 1: Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 3: Success rate at first attempt
1.4
1.4. Analysis
Comparison 1: Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 4: Non‐airway‐related adverse effects: desaturation or bradycardia episodes, or both
1.5
1.5. Analysis
Comparison 1: Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 5: Non‐airway‐related adverse effects: lowest saturations during intubation
1.6
1.6. Analysis
Comparison 1: Videolaryngoscopy (VDL) versus conventional direct laryngoscopy (CDL), Outcome 6: Airway‐related adverse effects: airway trauma

Update of

References

References to studies included in this review

Bartle 2019 {published and unpublished data}
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    1. Kamath N, Dogra N, Gupta A. Comparison of ease of intubation with airtraq optical laryngoscope versus Miller laryngoscope in neonates – a randomised interventional study. Indian Journal of Anaesthesia 2020;64(13):S24-5.
Moussa 2016 {published data only}
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Salama 2019 {published data only}
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Singh 2009 {published data only}
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Tao 2019 {published data only}
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References to studies excluded from this review

Fiadjoe 2012 {published and unpublished data}
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References to studies awaiting assessment

Chae 2022 {published and unpublished data}
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Jain 2018 {published data only}
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Yumul 2013 {published and unpublished data}
    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]. https://clinicaltrials.gov/ct2/show/NCT01371032 (first received 10 June 2011).
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References to ongoing studies

ACTRN12614001134617 {unpublished data only}
    1. ACTRN12614001134617. A randomised controlled clinical trial comparing C-MAC (™) videolaryngoscope intubation with direct laryngoscope intubation in neonates. The HEADS UP Study. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367096 (first received 24 October 2014).
CTRI/2021/06/034029 {published data only}
    1. CTRI/2021/06/034029. Comparison of two videolaryngoscopes with direct laryngoscope for endotracheal intubation in neonates undergoing surgery under general anaesthesia. trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2021/06/034029 (first received 7 June 2021).
CTRI/2022/04/041925 {published data only}
    1. CTRI/2022/04/041925. Comparison of MacGrath video laryngoscope and Macintosh laryngoscope for intubation in neonatal patients. trialsearch.who.int/Trial2.aspx?TrialID=CTRI/2022/04/041925 (first received 19 April 2022).
CTRI/2022/07/044293 {published data only}
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DRKS00020792 {published data only}
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NCT04295902 {unpublished data only}
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NCT04994652 {published data only}
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References to other published versions of this review

Lingappan 2015
    1. Lingappan K, Arnold JL, Shaw TL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No: CD009975. [DOI: 10.1002/14651858.CD009975.pub3] - DOI - PubMed
Lingappan 2018
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