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Date of Award
Spring 2022
Degree Name
Master of Medical Science (Physician Assistant)
Department
Physician Assistant; College of Health Sciences
First Advisor
Diana Hawthorne, PA-C
Abstract
Background: Endotracheal intubation is a foundational skill of emergency and critical care clinicians. Direct laryngoscopy (DL) has long been the go-to method of intubation, but difficult airway characteristics can hinder clinicians' ability to intubate on their first attempt. Video laryngoscopy (VL) has been suggested as a tool to improve airway management in patients with problematic airway characteristics. However, current data comparing DL to VL has been predominately observational and has produced inconsistent findings.
Objective: The study's objective was to investigate if there is evidence to suggest that VL results in more first-pass intubation success and reduced complications compared to DL in patients needing emergent intubation.
Methods: A systematic review of EBSCO and PubMed databases was performed, examining for studies that compared VL and DL in the emergency department (ED) and intensive care unit (ICU). Relevant articles were then independently reviewed and filtered against various inclusion and exclusion criteria. The primary outcome was the overall rate of first-pass intubation success, with additional analyses based on clinician experience and type of VL used. The secondary outcome was the incidence of complication rates with either device.
Results: A total of 21,788 intubations were attempted across 12 studies with either DL (n = 12,527) or VL (n = 9,261). Data was presented as [odds ratio (95% confidence intervals); P values]. Overall rate of first-pass intubation was 80% and 75% for the VL and DL groups, respectfully [OR=1.35 (1.26–1.45); P<0.0001]. Compared to DL, VL had higher rates of first-pass success amongst less experienced physicians [80.46% vs. 71.66%; OR=1.63 (1.45–1.83); P<0.0001] and a lower incidence of esophageal intubations [1.27% vs. 6.02%; OR=4.93 (3.63–6.70); P<0.0001]. Amongst various VL devices, the CMAC VL led to more first-pass success when compared to the GVL [83.89% vs. 78.18%; OR=1.46 (1.25–1.69); P<0.0001]. DL was associated with greater first-pass success amongst experienced clinicians when compared to VL [81.88% vs 72.84%; OR=0.59 (0.52–0.68); P<0.0001] and decreased incidence of hypoxemia [12.91% vs. 16.88%; OR=1.37 (1.19–1.57); P<0.0001]. Complications such as airway trauma, hypotension, and aspiration were unchanged between the two groups.
Conclusion: The use of VL in patients undergoing emergent intubation was associated with a greater overall first-pass success rate when compared to DL, while also increasing first-pass success in inexperienced physicians and reducing the incidence of esophageal intubations. However, VL was associated with decreased first-pass success in experienced physicians and a greater incidence of hypoxemia. Further randomized controlled trials must be conducted to investigate the utility of VL over DL in the ED and ICU.
Recommended Citation
Handt, Tyler, "Video laryngoscopy versus direct laryngoscopy for endotracheal intubation in the emergency department and intensive care unit" (2022). Capstone Showcase. 16.
https://scholarworks.arcadia.edu/showcase/2022/pa/16
Video laryngoscopy versus direct laryngoscopy for endotracheal intubation in the emergency department and intensive care unit
Background: Endotracheal intubation is a foundational skill of emergency and critical care clinicians. Direct laryngoscopy (DL) has long been the go-to method of intubation, but difficult airway characteristics can hinder clinicians' ability to intubate on their first attempt. Video laryngoscopy (VL) has been suggested as a tool to improve airway management in patients with problematic airway characteristics. However, current data comparing DL to VL has been predominately observational and has produced inconsistent findings.
Objective: The study's objective was to investigate if there is evidence to suggest that VL results in more first-pass intubation success and reduced complications compared to DL in patients needing emergent intubation.
Methods: A systematic review of EBSCO and PubMed databases was performed, examining for studies that compared VL and DL in the emergency department (ED) and intensive care unit (ICU). Relevant articles were then independently reviewed and filtered against various inclusion and exclusion criteria. The primary outcome was the overall rate of first-pass intubation success, with additional analyses based on clinician experience and type of VL used. The secondary outcome was the incidence of complication rates with either device.
Results: A total of 21,788 intubations were attempted across 12 studies with either DL (n = 12,527) or VL (n = 9,261). Data was presented as [odds ratio (95% confidence intervals); P values]. Overall rate of first-pass intubation was 80% and 75% for the VL and DL groups, respectfully [OR=1.35 (1.26–1.45); P<0.0001]. Compared to DL, VL had higher rates of first-pass success amongst less experienced physicians [80.46% vs. 71.66%; OR=1.63 (1.45–1.83); P<0.0001] and a lower incidence of esophageal intubations [1.27% vs. 6.02%; OR=4.93 (3.63–6.70); P<0.0001]. Amongst various VL devices, the CMAC VL led to more first-pass success when compared to the GVL [83.89% vs. 78.18%; OR=1.46 (1.25–1.69); P<0.0001]. DL was associated with greater first-pass success amongst experienced clinicians when compared to VL [81.88% vs 72.84%; OR=0.59 (0.52–0.68); P<0.0001] and decreased incidence of hypoxemia [12.91% vs. 16.88%; OR=1.37 (1.19–1.57); P<0.0001]. Complications such as airway trauma, hypotension, and aspiration were unchanged between the two groups.
Conclusion: The use of VL in patients undergoing emergent intubation was associated with a greater overall first-pass success rate when compared to DL, while also increasing first-pass success in inexperienced physicians and reducing the incidence of esophageal intubations. However, VL was associated with decreased first-pass success in experienced physicians and a greater incidence of hypoxemia. Further randomized controlled trials must be conducted to investigate the utility of VL over DL in the ED and ICU.