Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

Abstract

Background: Whether video laryngoscopy as compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults is uncertain.

Methods: In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), we randomly assigned critically ill adults undergoing tracheal intubation to the video-laryngoscope group or the direct-laryngoscope group. The primary outcome was successful intubation on the first attempt. The secondary outcome was the occurrence of severe complications during intubation; severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death.

Results: The trial was stopped for efficacy at the time of the single preplanned interim analysis. Among 1417 patients who were included in the final analysis (91.5% of whom underwent intubation that was performed by an emergency medicine resident or a critical care fellow), successful intubation on the first attempt occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% confidence interval [CI], 9.9 to 18.7; P<0.001). A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct-laryngoscope group had a severe complication during intubation (absolute risk difference, 0.5 percentage points; 95% CI, -3.9 to 4.9). Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups.

Conclusions: Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope. (Funded by the U.S. Department of Defense; DEVICE ClinicalTrials.gov number, NCT05239195.).

Figure 1.. Cumulative Incidence of Successful Intubation on the First Attempt.

Shown are the cumulative incidence and 95% confidence intervals (shaded areas) for successful intubation on the first attempt among patients in each trial group relative to the time since the initial insertion of a laryngoscope blade into the mouth. Successful intubation on the first attempt occurred in 600 of 705 patients in the video-laryngoscope group and in 504 of 712 patients in the direct-laryngoscope group (absolute risk difference, 14.3 percentage points; 95% CI, 9.9 to 18.7; P<0.001 by the chi-square test).

Figure 2.. Subgroup Analyses of the Primary Outcome.

Shown are the absolute risk differences and 95% confidence intervals for the primary outcome (successful intubation on the first attempt) in the video-laryngoscope group as compared with the direct-laryngoscope group in each prespecified subgroup. Absolute risk differences were calculated with the use of a generalized linear mixed-effects model with a random effect for trial site and fixed effects for trial group, the proposed effect modifier, and the interaction between the trial group and the proposed effect modifier. Absolute risk differences of greater than 0 indicate a higher likelihood of successful intubation on the first attempt with use of a video laryngoscope. The body-mass index is the weight in kilograms divided by the square of the height in meters.