Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators

doi:10.1016/j.resuscitation.2016.04.003

Resuscitation

Volume 105, August 2016, Pages 196-202

https://doi.org/10.1016/j.resuscitation.2016.04.003 Get rights and content

Abstract

Aim

This study compared endotracheal intubation (ETI) performance during cardiopulmonary resuscitation (CPR) between direct laryngoscopy (DL) and video laryngoscopy (VL) (GlideScope^®) by experienced intubators (>50 successful ETIs).

Methods

This was a prospective randomized controlled study conducted in an emergency department between 2011 and 2013. Intubators who used DL or VL were randomly allocated to ETI during CPR. Data were collected from recorded video clips and rhythm sheets. The success, speed, complications, and chest compressions interruption were compared between the two devices.

Results

Total 140 ETIs by experienced intubators using DL (n = 69) and VL (n = 71) were analysed. There were no significant differences between DL and VL in the ETI success rate (92.8% vs. 95.8%; p = 0.490), first-attempt success rate (87.0% vs. 94.4%; p = 0.204), and median time to complete ETI (51 [36–67] vs. 42 [34–62] s; p = 0.143). In both groups, oesophageal intubation and dental injuries seldom occurred. However, longer chest compressions interruption occurred using DL (4.0 [1.0–11.0] s) compared with VL (0.0 [0.0–1.0] s) and frequent serious no-flow (interruption > 10 s) occurred with DL (18/69 [26.1%]) compared with VL (0/71) (p < 0.001). For highly experienced intubators (>80 successful ETIs), frequent serious no-flow occurred in DL (14/55 [25.5%] vs. 0/57 in VL).

Conclusions

The ETI success, speed and complications during CPR did not differ significantly between the two devices for experienced intubators. However, the VL was superior in terms of completion of ETI without chest compression interruptions.

Trial Registration

Clinical Research Information Service (CRIS) in South Korea KCT0000849.

Introduction

Endotracheal intubation (ETI) is considered to be the best method of airway management during cardiopulmonary resuscitation (CPR).¹ However, despite its life-saving intent, ETI can have latent risks for survival in arrest patients.2, 3 Compared with ETI of non-arrest patients, ETI during CPR has higher risks of failure or delayed success with frequent attempts, misplacement of the tube, and prolonged interruptions of chest compressions.4, 5, 6 The ERC guidelines recommend that ETI during CPR should be attempted only if the health-care provider is properly trained and has regular, ongoing experience with the technique.¹

The main problems associated with ETI relate to the inherently technical difficulty in using direct laryngoscopy (DL), which is the standard device. Various types of video laryngoscopy (VL) devices using microcamera technology have been developed to overcome the problems of DL, and the use of VL has increased in operating rooms and intensive care units.⁷ For ETI during CPR, a paradigm shift to change from using DL to VL has been suggested because VL may be easier to learn and faster when performing ETI, and may reduce the risk of complications.8, 9 Positive results from various simulation trials support this suggestion.

However, most specialists may require evidence obtained beyond the simulation setting. Although VL is being used particularly by novice physicians in clinical arrest settings, there is little clinical evidence of the use of VL by experienced physicians.1, 10 It seems that many experienced physicians, who are mainly responsible for ETI in the real-world clinical environment, may be not consider VL as a primary device for ETI during CPR now. To investigate the possibility that new VL is new primary device for ETI during cardiac arrest, more clinical studies including experienced intubators are needed.

The study aimed to compare the success rate of ETI, speed of ETI, incidence of complications, and chest compression interruptions between experienced intubators using DL and VL in a clinical setting.

Section snippets

Study design and setting

This was a prospective randomized controlled study conducted in the emergency department (ED) at an urban 870-bed tertiary training hospital. The study protocol was reviewed and approved by the Institutional Review Board for Human Research at our institution (approval number KUH005126). In our ED, over 50,000 patients annually visit for emergency care, and >150 out-of-hospital arrest patients are transported to the ED for advanced life support. The advanced cardiovascular life support (ACLS)

Baseline data

During the 24-month study period, 325 CPRs were performed in cardiac arrest patients; 311 were out-of-hospital arrests and 14 were in-hospital arrests treated at the ED. A total of 270 ETIs were performed during ongoing chest compressions in 237 patients, and 130 of these ETIs were excluded for the following reasons: ETI on patients wearing a cervical collar (n = 7), ETI performed by an inexperienced intubator (n = 120) and poor recording quality (n = 3). A total of 140 ETIs were included in the

Discussion

From the early 20th century, DL has been used as the airway device of choice for viewing the glottis.¹³ ETI techniques using DL are highly dependent of personal skills, and experience with the procedure is indispensable for acquiring sufficient proficiency in ETI.12, 14 With advances in technology, two noticeable milestones in advanced airway management have been introduced to overcome the difficulties in using this device. First was the supraglottic airway (SGA) device, which has been used

Conclusions

For experienced intubators, DL and VL had similar high success rates for ETI and rare complications. However, serious no-flow during CPR occurred in ETI using DL, but not in VL. For arrest patients, VL was superior to DL as an airway device for completing ETI without serious chest compression interruptions.

Conflict of interest statement

All authors have no conflicts of interest to declare.

Acknowledgement

This paper was supported by Konkuk University.

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Cited by (50)

Video laryngoscopy and direct laryngoscopy for cardiac arrest: A meta-analysis of clinical studies and trials
2023, American Journal of Emergency Medicine
Intubation is an essential procedure in cardiopulmonary resuscitation (CPR). We conducted a systematic review and meta-analysis of trials and studies comparing the performance of video laryngoscope (VL) and direct laryngoscope (DL) in endotracheal intubation (ETI) during CPR in cardiac arrest (OHCA) patients.
We searched the PUBMED, EMBASE, and Cochrane library databases. We analyzed the first-pass success rate, total intubation time, Cormack–Lehane grade (CL grade), esophageal intubation rate, and dental injury rate among the in-hospital cardiac arrest (IHCA) patients or out-of-hospital cardiac arrest (OHCA) patients. We demonstrated the pooled results of continuous outcomes by mean difference (MD) and dichotomous outcomes by odds ratio (OR), with a 95% confidence interval (CI) using a random-effects model.
We obtained six observational studies and one randomized control trial. The pooled results showed a significant increase in first-pass success rate (OR: 1.86, 95% CI: 1.41, 2.47), Cormack–Lehane (CL) grade (OR: 2.01, 95% CI: 1.59,2.53), and a decrease of esophageal intubation rate (OR: 0.25, 95% CI: 0.08, 0.85) in the VL group compared with DL group. Also, a non-significant decrease in dental injury rate [OR: 0.23, 95% CI: 0.05, 1.08) was observed in the VL group compared with the DL group. There was no statistical difference between the VL and DL groups, although the VL group seemed to have a shorter total intubation time (MD: -15.43, 95% CI: −34.67, 3.81). Types of laryngoscopes were not associated with the rate of ROSC [OR 1.01 (0.95,1.07); P = 0.83]. No differences in survival outcomes were observed between the two approaches.
Compared to DL, VL was found to be associated with first-pass success and CL grade. We recommend prioritizing VL over DL when performing ETIs for patients with cardiac arrest.
First attempt success with continued versus paused chest compressions during cardiac arrest in the emergency department
2023, Resuscitation
Tracheal intubation is associated with interruption in cardiopulmonary resuscitation (CPR). Current knowledge of tracheal intubation during active CPR focuses on the out-of-hospital environment. We aim to describe characteristics of tracheal intubation during active CPR in the emergency department (ED) and determine whether first attempt success was associated with CPR being continued vs paused.
We reviewed overhead video from adult ED patients receiving chest compressions at the start of the orotracheal intubation attempt. We recorded procedural detail including method of CPR, whether CPR was continued vs paused, and first attempt intubation success (primary outcome). We performed logistic regression to determine whether continuing CPR was associated with first attempt success.
We reviewed 169 instances of tracheal intubation, including 143 patients with continued CPR and 26 patients with paused CPR. Those with paused CPR were more likely to be receiving manual rather than mechanical chest compressions. Video laryngoscopy and bougie use were common. First attempt success was higher in the continued CPR group (87%, 95% CI 81% to 92%) than the interrupted CPR group (65%, 95% CI 44% to 83%, difference 22% [95% CI 3% to 41%]). The multivariable model demonstrated an adjusted odds ratio of 0.67 (95% CI 0.17 to 2.60) for first attempt intubation success when CPR was interrupted vs continued.
It was common to continue CPR during tracheal intubation, with success comparable to that achieved in patients without cardiac arrest. It is reasonable to attempt tracheal intubation without interrupting CPR, pausing only if necessary.
Does video laryngoscopy significantly improve clinical outcomes in patients with cardiac arrest?
2023, Resuscitation
Effect of video laryngoscopy for non-trauma out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis
2023, Resuscitation
Videolaryngoscopy (VL) is a promising tool to provide a safe airway during cardiopulmonary resuscitation (CPR) and to ensure early reoxygenation. Using data from the German Resuscitation Registry, we investigated the outcome of non-traumatic out-of-hospital cardiac arrest (OHCA) patients treated with VL versus direct laryngoscopy (DL) for airway management.
We analysed retrospective data of 14,387 patients from 1 January 2018 until 31 December 2021 (VL group, n = 2201; DL group, n = 12186). Primary endpoint was discharge with cerebral performance categories one and two (CPC1/2). Secondary endpoints were the rate of return of spontaneous circulation (ROSC), hospital admission, hospital admission with ongoing cardiopulmonary resuscitation, 30-day survival/ hospital discharge and airway management complications. We used multivariate binary logistic regression analysis to identify the effects on outcome of known influencing variables and of VL vs DL.
The multivariate regression model revealed that VL was an independent predictor of CPC1/2 survival (OR = 1.34, 95% CI = 1.12–1.61, p = 0.002) and of hospital discharge/30-day survival (OR = 1.26, 95% CI = 1.08–1.47, p = 0,004).
VL for endotracheal intubation (ETI) at OHCA was associated with better neurological outcome in patients with ROSC. Therefore, the use of VL for OHCA offers a promising perspective. Further prospective studies are required.
Videolaryngoscopy versus direct laryngoscopy for endotracheal intubation of cardiac arrest patients in hospital: A systematic literature review
2022, Resuscitation Plus
Citation Excerpt :
Across the six studies and 4525 patients, a total of 1124 (25 %) patients were intubated using VL whereas 3401 (75 %) patients were intubated using DL. Three of the studies maintained a proportionate split between the groups,16–17,20 and three had a very uneven split between intervention and control. The experience of clinician that performed the intubation varied throughout the studies, with Park et al.19 focussing on novice physicians, Kim et al.20 using clinicians they classified as being experienced, and the remaining studies using clinicians with a variety of experiences.
Airway management during cardiopulmonary resuscitation may involve endotracheal intubation complicated by associated difficulties. Videolaryngoscopy may help to ease these difficulties and increase success rates by removing the need to achieve a direct line of sight required by standard direct laryngoscopy. This literature review aims to establish if there is an overall benefit in using videolaryngoscopy over direct laryngoscopy when intubating patients during cardiac arrest in the non-theatre hospital environment.
The review was registered on PROSPERO (record ID 329987). A systematic search was conducted of EMBASE, MEDLINE, CINAHL and Web of Science for literature comparing the use of videolaryngoscopy to direct laryngoscopy during intubation of cardiac arrest patients in hospital up until 4th May 2022. The Cochrane Central Register of Controlled Trials (CENTRAL) database was accessed, and reference lists of relevant systematic reviews were analysed for further papers. Forward and backward citation tracking was carried out of the shortlisted papers to hand-search for any further relevant studies. Papers were included in the review if they used adult patients, the patients were intubated during cardiac arrest in hospital and if the papers were in English language or had an accessible translation. Papers were excluded if patients were intubated not during cardiac arrest, the studies were based outside of a hospital setting or in the operating theatre, the patients were paediatric or if the study used a simulation or manikin. The Critical Appraisal Skills Programme checklists were used to assess risk of bias. Odds ratios, confidence intervals and probability values were used to synthesise results.
Six studies were identified that collectively analysed 4525 patients who were intubated during cardiac arrest in the non-theatre hospital environment; five studies were observational and one a randomised controlled trial. Most of the studies being observational in nature led to a significant bias in their methodology which is a limitation to this review. The studies all measured first pass success rate as the primary outcome. First pass success rate only improved with videolaryngoscopy compared to direct laryngoscopy when the intubator was a less experienced clinician. Videolaryngoscopy also reduced some endotracheal intubation related complications and improved glottic visualisation when compared to direct laryngoscopy.
The limited data suggests that use of videolaryngoscopy improved first pass success rates compared to direct laryngoscopy when the clinician was less experienced.
Ultra-slippery, nonirritating, and anti-inflammatory hyaluronic acid-based coating to mitigate intubation injury
2022, Chemical Engineering Journal
Citation Excerpt :
Endotracheal intubation has been extensively applied in various clinical settings, such as cardiopulmonary resuscitation, respiratory disease, and anesthesiology [1–3].
Endotracheal intubation is a crucial procedure for mechanical ventilation and respiratory support therapy. However, friction mismatch between the tube material and tissues often causes complications, such as laryngopharyngeal airway mucosa injury, tracheal granuloma, and inflammatory reaction. In this work, a highly lubricated coating was designed and applied on the tracheal tube. Hyaluronic acid (HA) and triblock copolymer (Pluronic F127) were co-deposited on the surface-activated tube to form a hydration layer through intermolecular interaction. The coating exhibited high artificial saliva adsorption ratio and water-retention rate, providing excellent lubrication to the tube. The friction coefficient of the coated tube in artificial saliva was 77% less than that observed for the original tube. The efficacy of the lubricated coating on endotracheal intubation was assessed in vivo by using a cynomolgus monkey model. The coating was demonstrated to be effective to alleviate the injury caused by endotracheal intubation.

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^☆: A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2016.04.003.

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Clinical paperVideo laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators☆

Abstract

Aim

Methods

Results

Conclusions

Trial Registration

Introduction

Section snippets

Study design and setting

Baseline data

Discussion

Conclusions

Conflict of interest statement

Acknowledgement

Resuscitation

Ann Emerg Med

Resuscitation

Resuscitation

Resuscitation

Br J Anaesth

J Clin Anesth

Resuscitation

Resuscitation

J Clin Anesth

Am J Emerg Med

Resuscitation

Resuscitation

Clinical paper
Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators☆