Photo Credit: Isaac Lee
The standard of care for endotracheal intubation continues to be direct laryngoscopy, despite the demonstrated superiority of hyperangulated video laryngoscopy.
Safe airway management is a significant concern for many critical care healthcare professionals, including surgeons, anesthesiologists, and emergency medicine practitioners. Despite the availability of more technologically advanced options, such as video laryngoscopy, the standard of care in administering endotracheal intubation continues to be direct laryngoscopy.
Suspecting the potential superiority of video laryngoscopy compared to direct laryngoscopy, Kurt Ruetzler, MD, and colleagues developed a cluster-randomized multiple crossover clinical trial conducted at a single US academic hospital to compare the outcome of hyperangulated video laryngoscopy compared to direct laryngoscopy for the initial intubation attempt of patients in need of airway management. The trial sought to determine which of the two procedures required fewer intubation attempts and which produced fewer intubation failures as well as dental and airway injuries.
The researchers published the results of the trial in JAMA. Physician’s Weekly (PW) spoke with Dr. Ruetzler regarding the findings.
PW: Why did this topic need exploration?
Dr. Ruetzler: Airway management is generally believed to be safe, simple, and nearly always ultimately successful. However, these assumptions are wrong. According to recent data from the UK, the incidence of airway complications is nearly 2% and is the leading cause of perioperative cardiac arrest. Nearly 13% of all cardiac arrests and more than 9% of deaths are the consequence of difficulties during airway management. Every single intubation attempt increases the risk of patients’ morbidity and mortality. Therefore, it is essential to identify more successful airway devices and techniques.
What are the most important findings from your study, particularly for those who work in an emergency room setting?
Video laryngoscopy is superior to direct laryngoscopy, the established global gold standard for endotracheal intubation. There are three important findings of this important landmark trial:
- Using video laryngoscopy as the default intubation device, only 1.7 % of patients required more than one intubation attempt, compared to 7.7% if using direct laryngoscopy.
- An alternate device (defined as intubation failure in our trial) was required in only 0.27% of the video laryngoscopy group versus 4% of the direct laryngoscopy group. This is important, as an alternate device requires additional equipment and personnel, ultimately adding substantial costs to the care provided.
- Video laryngoscopy and direct laryngoscopy are equally safe, and neither technique increases the risk of dental and/or airway injuries.
How can physicians incorporate these findings into practice?
It’s time to move on and change our daily clinical practice. Physicians are strongly encouraged to use video laryngoscopy as the default technique in all patients. There is just no doubt that video laryngoscopy is superior to direct laryngoscopy.
What makes this issue particularly urgent in the healthcare landscape?
Only one single matter counts in perioperative medicine: the patient. Our common goal as physicians and scientists is to make healthcare safer by reducing patient morbidity. As scientists, we provide robust and convincing evidence. And now clinicians are asked to translate this into everyday clinical practice.
What would you like future research to be focused on? What do you think still needs to be explored?
Clinical research needs to focus on patient-centered and clinically relevant outcomes (like morbidity) rather than surrogate outcomes (like time to intubation), which may or may not be clinically important. The majority of airway research is done, and only minor questions need to be answered. For example, the indicated awake intubation can be further explored.
