Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants
The New England Journal of Medicine
Submitted November 2024 by Dr Siak Lee
Read by 58 Journal Watch subscribers
Study Overview:
This study compares first pass intubation success using video vs. direct laryngoscopy in neonates.
Methods:
Single centre, randomised, prospective trial of 214 patients at a tertiary centre in Dublin Ireland.
Two intervention arms:
- Videolaryngoscope (VL)
- Direct laryngoscope (DL)
The majority of proceduralists were paediatric and neonatal registrars who were allowed a maximum 3 attempts. The most senior clinician in attendance made the decision to intubate. Neonatologists could intervene at any time.
Eligibility:
Inclusion
• Neonates of any gestational age intubated in the Delivery Room (DR) or NICU
• Patients included only once
• Neonates transferred from other hospitals included if intubated at author institute
Excluded
• Neonates with upper airway abnormalities
Findings:
Significant increase in first pass intubation success with videolaryngoscope compared to direct laryngoscopy (74% vs. 45%, P < 0.001)
Secondary outcomes, none statistically significant:
- Median number of successful attempts 1 vs. 2 (VL vs. DL)
- Median duration of time to successful intubation on first attempt 61 vs. 51 secs (VL vs. DL)
- Lowest median SpO2 74% vs. 68% (VL vs. DL)
- Lower median HR 153 vs. 148 bpm (VL vs. DL)
- Oral trauma 0% vs. 1% (VL vs. DL)
- ETT tip in correct position of chest radiograph 53% vs. 50% (VL vs. DL)
- Crossover 3% vs 29% (VL vs DL)
Take Home Messages and Commentary
1) Does the study address a relevant and / or important question?
For junior operators with little to no experience intubating neonates, there was a significantly higher first pass urgent intubation success rate with video laryngoscopy compared to direct laryngoscopy (74% vs. 45% VL vs. DL). Overall, higher intubation was successfully completed with videolaryngoscope (96% vs. 69% VL vs. DL, Supplementary). However, time to successful intubation was longer when using video laryngoscopy (61 vs. 51 seconds VL vs. DL).
2) Is there any recent research, evidence, or study on a similar question?
In critically ill adult populations in USA, video laryngoscopy increased first pass intubation success compared to direct laryngoscopy (Silverberg 2015). The data in paediatric and neonatal populations are conflicting. In an updated Cochrane review, ‘low certainty’ was given to VL and its ability to increase first attempt success in neonatal intubation. In addition this Cochrane review was not confident that the introduction of VL in the neonatal population would lead to fewer intubation attempts and may not reduce time required for successful intubation. However it was moderately certain that there was decreased airway trauma with neonatal VL (Lingappan et al 2023).
3) What are the strengths of the study?
• Single centre – standardisation of practise
• Tertiary centre – high complexity
• Attempts to minimise bias
• Randomisation
• Very similar medications given
• Independent data collectors
• Clinically meaningful data with statistical significance
4) What are the limitations of the study?
• Non-blinded
• Not necessarily applicable to LMIC or regional/remote centre due to high cost of purchasing video laryngoscopy
• Only one type of Video laryngoscopy was used – Miller blade
• No collection of data on
• Specific previous experience of practitioners
• Grade of laryngeal view
• Reasons for discontinuing attempts
• This study did not include neonates with upper airway abnormalities
5) Is the study applicable to our practice or to our population?
Yes
• Majority of first operators were junior clinicians
• English speaking, Western, European – similar cohort to Australia
References:
1. Silverberg MJ, N L, So A, Pd K. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Critical care medicine. 2015;43(3). doi:10.1097/CCM.0000000000000751
2. Lingappan K, Neveln N, Arnold JL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates - Lingappan, K - 2023 | Cochrane Library. Accessed October 16, 2024. https://www.cochranelibrary.com/cdsr/doi/10.1
002/14651858.CD009975.pub4/full
