Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants.

BACKGROUND: Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain. METHODS: In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection. RESULTS: Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively. CONCLUSIONS: Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.).

A novel combined approach to placement of a double lumen endobronchial tube using a video laryngoscope and fiberoptic bronchoscope: a retrospective chart review.

BACKGROUND: The objective of this study was to evaluate a modern combined video laryngoscopy and flexible fiberoptic bronchoscope approach to placement of a double lumen endobronchial tube and further characterize potential strengths and weaknesses of this approach. METHODS: Retrospective chart review was conducted at our single institution, academic medical center, tertiary-care hospital. Patients aged 18 years of age or older were evaluated who underwent thoracic surgery and one-lung ventilation with placement of a double lumen endobronchial tube using a novel combined video laryngoscopy and flexible fiberoptic bronchoscope approach. No interventions were performed. RESULTS: Demographics and induction and intubation documentation were reviewed for 21 patients who underwent thoracic surgery and one-lung ventilation with placement of a double lumen endobronchial tube using a novel combined video laryngoscopy and flexible fiberoptic bronchoscope approach. First pass success using the combined approach was 86% (18/21). The five patients with an anticipated difficult airway had successful double lumen endobronchial tube placement on the first attempt. There were no instances of desaturation during double lumen endobronchial tube placement. No airway complications related to double lumen endobronchial tube placement were recorded. CONCLUSION: Use of a combined approach employing video laryngoscopy and a flexible fiberoptic bronchoscope may represent a reliable alternative approach to placement of double lumen endobronchial tubes.

Evaluation of a novel, low-cost, 3D printed video laryngoscope with borescope in anesthetized Beagle dogs.

OBJECTIVE: To develop and evaluate a low-cost three-dimensional (3D)-printed video laryngoscope (VLVET) for use with a commercial borescope. STUDY DESIGN: Instrument development and pilot study. ANIMALS: A total of six adult male Beagle dogs. METHODS: The VLVET consisted of a laryngoscope handle and a Miller-type blade, and a detachable camera holder that attached to various locations along the blade. The laryngoscope and camera holder were 3D-printed using black polylactic acid filament. Dogs were premedicated with intravenous (IV) medetomidine (15 µg kg-1) and anesthesia induced with IV alfaxalone (1.5 mg kg-1). The VLVET, combined with a borescope, was used for laryngeal visualization and intubation. Performance was evaluated by comparing direct and video-assisted views in sternal recumbency. The borescope camera was sequentially positioned at 2, 4, 6, 8 and 10 cm from the blade tip (distanceLARYNX-CAM), which was placed on the epiglottis during intubation or laryngoscopy. At the 10 cm distanceLARYNX-CAM, laryngeal visualization was sequentially scored at inter-incisor gaps of 10, 8, 6, 4 and 2 cm. Laryngeal visualization scores (0-3 range, with 0 = obstructed and 3 = unobstructed views) were statistically analyzed using the Friedman's test. RESULTS: Under direct visualization, the 2 cm distanceLARYNX-CAM had a significantly lower score compared with all other distanceLARYNX-CAM (all p = 0.014) because the view was obstructed by the camera holder and borescope camera. With both direct and camera-assisted views, visualization scores were higher at inter-incisor gaps ≥ 4 cm compared with 2 cm (all p < 0.05). CONCLUSIONS AND CLINICAL RELEVANCE: During laryngoscopy and intubation, the VLVET and borescope facilitated both direct and video laryngoscopy at distanceLARYNX-CAM in Beagle dogs when inter-incisor gaps were ≥ 4 cm.

Left head rotation (LeHeR), an innovative approach for intubation in patients with missing and loose teeth.

Missing and loose central incisors pose a great difficulty to anaesthesiologists during laryngoscopy and intubation. Left head rotation is a novel technique which facilitates intubation by improving the laryngoscopic view. We report the use of this technique in two patients with missing or loose central incisors to prevent dental trauma.

Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial.

Importance: Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear. Objective: To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy. Design, Setting, and Participants: Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat. Interventions: Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt. Main Outcomes and Measures: The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries. Results: Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]). Conclusion and Relevance: In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures. Trial Registration: ClinicalTrials.gov Identifier: NCT04701762.

Design and Usability of an Open-Source, Low-Cost Flexible Laryngoscope for Resource-Limited Settings.

Importance: Endoscopes are paramount to the practice of otolaryngology. To provide physicians in low-middle-income countries with adequate tools to treat otolaryngologic problems, it is necessary to create a low-cost sustainable option. Objective: To describe the design and usability of an open-source, low-cost flexible laryngoscope that addresses the lack of affordable and accessible methods for otolaryngologic visualization in resource-limited settings. Design, Setting, and Participants: This quality improvement study used a mixed-methods approach, including a technical description of device design as well as quantitative and qualitative survey evaluation of device usability. Engineering involved device design, sourcing or manufacturing individual components, fabricating a prototype, and iterative testing. Key assumptions and needs for the device were identified in collaboration with otolaryngologists in Zimbabwe, and designed and simulated by biomedical engineers in a US university laboratory. Board-certified otolaryngologists at a single US university hospital trialed a completed prototype on simulated airways between May 2023 and June 2023. Main Outcomes and Measures: Technical details on the design of the device are provided. Otolaryngologist gave feedback on device characteristics, maneuverability, and visualization using the System Usability Scale, a customized Likert-scale questionnaire (5-point scale), and semistructured interviews. Results: A functional prototype meeting requirements was completed consisting of a distal-chip camera, spring bending tip, handle housing the control mechanism and electronics, and flexible polyether block amide-coated silicone sheath housing the camera and control wires; an external monitor provided real-time visualization and ability to store data. A total of 14 otolaryngologists participated in the device review. The mean (SD) System Usability Scale score was 88.93 (10.08), suggesting excellent usability. The device was rated highly for ease of set up, physical attributes, image quality, and functionality. Conclusions and Relevance: This quality improvement study described the design of a novel open-source low-cost flexible laryngoscope that external review with otolaryngologists suggests was usable and feasible in various resource-limited environments. Future work is needed to translate the model into a clinical setting.

A prospective, pragmatic non-inferiority study of emergency intubation success with the single-use i-view versus standard reusable video laryngoscope.

INTRODUCTION: Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site. METHODS: We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis. RESULTS: There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin. CONCLUSIONS: The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.

Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Intubating a patient in an emergent setting presents significant challenges compared to planned intubation in an operating room. This study aims to compare video laryngoscopy versus direct laryngoscopy in achieving successful endotracheal intubation on the first attempt in emergency intubations, irrespective of the clinical setting. METHODS: We systematically searched PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception until 27 February 2023. We included only randomized controlled trials that included patients who had undergone emergent endotracheal intubation for any indication, regardless of the clinical setting. We used the Cochrane risk-of-bias assessment tool 2 (ROB2) to assess the included studies. We used the mean difference (MD) and risk ratio (RR), with the corresponding 95% confidence interval (CI), to pool the continuous and dichotomous variables, respectively. RESULTS: Fourteen studies were included with a total of 2470 patients. The overall analysis favored video laryngoscopy over direct laryngoscopy in first-attempt success rate (RR = 1.09, 95% CI [1.02, 1.18], P = 0.02), first-attempt intubation time (MD = - 6.92, 95% CI [- 12.86, - 0.99], P = 0.02), intubation difficulty score (MD = - 0.62, 95% CI [- 0.86, - 0.37], P < 0.001), peri-intubation percentage of glottis opening (MD = 24.91, 95% CI [11.18, 38.64], P < 0.001), upper airway injuries (RR = 0.15, 95% CI [0.04, 0.56], P = 0.005), and esophageal intubation (RR = 0.37, 95% CI [0.15, 0.94], P = 0.04). However, no difference between the two groups was found regarding the overall intubation success rate (P > 0.05). CONCLUSION: In emergency intubations, video laryngoscopy is preferred to direct laryngoscopy in achieving successful intubation on the first attempt and was associated with a lower incidence of complications.

Sex Disparities in Applied Force on Maxillary Incisors Among Novices During Laryngoscopy Using a High-Fidelity Simulator: A Prospective Observational Study.

Endotracheal intubation (ETI) is a common and crucial intervention. Whether the performance of ETI differs according to the sex of the laryngoscopist remains unclear. The aim of this study was to assess sex disparities in markers of ETI performance among novices using a high-fidelity simulator. This prospective observational study was conducted from April 2017 to March 2019 in a public medical university. In total, 209 medical students (4th and 5th grade) without clinical ETI experience were recruited. Of the 209 students, 64 (30.6%) were female. The participants used either a Macintosh direct laryngoscope or C-MAC video laryngoscope in combination with a stylet or gum-elastic bougie to perform ETI on a high-fidelity simulator. The primary endpoint was the maximum force applied on the maxillary incisors during laryngoscopy. The secondary endpoint was the time to ETI. The implanted sensors in the simulator automatically quantified the force and time to ETI. The maximum force applied on the maxillary incisors was approximately 30% lower in the male than female group for all laryngoscopes and intubation aids examined (all P < 0.001). Similarly, the time to ETI was approximately 10% faster in the male than female group regardless of the types of laryngoscopes and intubation aids used (all P < 0.05). In this study, male sex was associated with a lower maximum force applied on the maxillary incisors during both direct and indirect laryngoscopy performed by novices. A clinical study focusing on sex differences in ETI performance is needed to validate our findings.