Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults

M.E. Prekker ME, B.E. Driver BE, S.A. Trent, D. Resnick‑Ault TD, et al. N Engl J Med. 2023 Jun 16. [CrossRef] [PubMed]

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. In a multicenter, randomized trial conducted at 17 emergency departments and intensive care units (ICUs), critically ill adults undergoing tracheal intubation were randomly assigned to the video-laryngoscope group or the direct-laryngoscope group. 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). 

Both groups had similar rates of severe complications (peripheral oxygen saturation, <80%, systolic blood pressure <65 mm Hg, new or increased use of vasopressors, cardiac arrest, or death): 21.4% vs 20.9%. The median time of an intubation attempt was 38 seconds and 46 seconds respectively. Safety outcomes, including esophageal intubation, injury to the teeth, and aspiration, were similar in the two groups. 

This trial has several strengths including randomization, an independent observer to prevent observer bias, and low numbers of missing data. However, there were also limitations. The video laryngoscope and the shape of the blade were not standardized, neither were the stylets and bougies utilized. Because 97% of the operators had performed fewer than 250 previous tracheal intubations, the findings may not apply to operators with more experience. 

Additional considerations include the patient’s airway anatomy, positioning, and anticipation of hemoptysis and emesis that will distort the view of the glottis. The COVID-19 pandemic showed us that speed may also be important especially in those very critically ill patients who cannot tolerate more than 20 seconds while attempting to secure the airway. Being familiar with your institution's airway tools is also important because not all hospitals have the same laryngoscopes, stylets or bougies.

Reviewed by Evan D Schmitz MD