Video no better than direct laryngoscopy for ICU intubations

Video laryngoscopy did not improve first-pass orotracheal intubation rates in the intensive care unit (ICU) and was associated with higher rates of life-threatening complications, in a multicentre study in France.
“Previous studies have shown conflicting results regarding the systematic use of video laryngoscopy for intubation in the ICU,” Dr. Jean Baptiste Lascarrou of District Hospital Center in La Roche Sur Yon told Reuters Health by email. Part of the reason could be that, in contrast to the operating room, “intubation in the ICU is frequently performed by residents and patients are in acute respiratory and/or circulatory failure.”
In 2015 and 2016, Dr. Lascarrou and colleagues at seven ICUs in France randomized 371 adults (mean age, 63; 37% women) to intubation with the McGrath Mac Videolaryngoscope or the Macintosh Laryngoscope.
The proportion of patients with successful first-pass intubation did not differ significantly between the groups (67.7% for video versus 70.3% for direct laryngoscopy; P=0.60).
Similarly, the proportion of first-attempt intubations performed by non-experts – mainly residents – did not differ between the groups (84.4% with video versus 83.2% with direct laryngoscopy; P=0.76). For video laryngoscopy, first intubation attempts were successful more often when performed by experts (55 of 60 patients, or 91.7%) versus non-experts (201 of 311 patients, or 64.6%; P=0.001)
Median time to successful intubation was three minutes for both groups (P=0.95).
The proportion of patients with severe life-threatening complications was higher in the video group compared to the direct laryngoscopy group (9.5% versus 2.8%, respectively; P=0.01). No significant between-group difference was found for mild-to-moderate life-threatening complications.
Dr. Lascarrou noted that “the frequency of life-threatening complications was relatively low overall compared to older studies, probably due to the systematic application of an intubation protocol that includes pre-oxygenation and neuromuscular blockade use.”
Nonetheless, he concluded, “Clinicians have a long way to go before the intubation process is safer in the ICU.”
Editorialists Drs. Brian O’Gara and Daniel Talmor, from the Department of Anesthesia, Critical Care, and Pain Medicine at Beth Israel Deaconess Medical Center in Boston, told Reuters Health, “This trial illustrates an important concept in modern medicine. The proliferation and increased availability of sophisticated devices such as the video laryngoscope with proven benefit in limited populations may sometimes lead clinicians to assume that such benefits can be applied to larger patient groups.”
“Studies such as (this) are important so that clinicians who may be using such devices can be informed as to their potential benefit or harm in patient groups who are different from the originally intended population,” they said by email.