British Journal of Anaesthesia 2017; 119 (3): 369-83.
https://doi.org/10.1093/bja/aex228
Background
Tracheal intubation is used for airway management in 38.4% of general anaesthetics – 1.1 million procedures per year (UK data). Difficult intubation occurs in 1-6% of cases (66,000 cases/year). Failed intubation occurs in 0.1-0.3% of cases (3,300 cases/year).
Method
In this meta-analysis, 64 randomised controlled trials (7044 participants >16 years old) comparing video laryngoscopy (VL – included 13 different types of VL) versus direct laryngoscopy (DL – using Macintosh blade), primarily in elective theatre (61 elective theatres). 1 ED, 1 ICU and 1 out of hospital studies were included.
Results
VL is favourable compared to DL in terms of successful intubation, but on subgroup analysis this is only significant if the intubator is experienced i.e >20 intubations with VL. In addition, VL is advantageous in patients with predicted difficult airway, better at achieving a good view (Grade 1-2), reducing laryngeal trauma, reducing voice hoarseness and increasing ease of intubation.
There were no significant differences between VL and DL in less experienced hands (<20 intubations with VL) in terms of mortality rate, hypoxia, sore throat, number of attempts, and successful first attempt
at intubation.
Stated Limitations from Study
Heterogeneity
– 9 types of VL vs DL
– Intubator of varying experience
– Range of patient population (in terms of normal vs predicted difficult airway)
Primarily elective theatres
– Only 1 study each for ED, ICU and out of hospital
Discussion from Journal Club meeting
Trainees should be encouraged to familiarise themselves with using VL
Limited VL available in department therefore DL will still be primary device
Consider VL in patient with predicted difficult airway
Patient preparation (i.e optimal position, adequately paralysed etc.) should remain main focus
Summary by Dr A. Tan. Journal Club 30 November 2017.
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