Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates)
Information
- DOI:
- https://doi.org/10.1002/14651858.CD011413.pub2Copy DOI
- Database:
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- Cochrane Database of Systematic Reviews
- Version published:
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- 24 May 2017see what's new
- Type:
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- Intervention
- Stage:
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- Review
- Cochrane Editorial Group:
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Cochrane Anaesthesia Group
- Copyright:
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- Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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Authors
Contributions of authors
Ibtihal S Abdelgadir (IA), Robert S Phillips (RP), Davinder Singh (DS), Michael P Moncreiff (MM), Joanne L Lumsden (JL).
Conceiving of the review: IA.
Co‐ordinating the review: IA, JL.
Undertaking manual searches: IA, MM, DS.
Screening search results: IA, MM, DS.
Organizing retrieval of papers: IA.
Screening retrieved papers against inclusion criteria: IA, MM, DS.
Appraising quality of papers: IA, DS.
Abstracting data from papers: IA, DS.
Writing to authors of papers for additional information: IA.
Providing additional data about papers: IA.
Obtaining and screening data on unpublished studies: IA.
Managing data for the review: IA, DS, MM, JL, RP.
Entering data into Review Manager 5 (RevMan 5.3): IA.
Analysing RevMan statistical data: IA, MM, JL, RP.
Performing other statistical analysis not using RevMan: IA, DS, JL, RP.
Interpreting data: IA, DS, JL, RP.
Making statistical inferences: IA, DS, JL, RP.
Writing the review: IA, DS, MM, JL, RP.
Securing funding for the review: IA.
Performing previous work that was the foundation of the present review: IA.
Serving as guarantor for the review (one review author): IA.
Taking responsibility for reading and checking the review before submission: IA, DS, MM, JL, RP.
Sources of support
Internal sources
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None, Other.
External sources
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No sources of support supplied
Declarations of interest
Ibtihal S Abdelgadir has submitted this Cochrane Review as a research thesis for partial fulfilment of a master degree in child health.
Joanne L Lumsden received a fee from Leeds University for participating in the Critical Illness module of the MSc in Child Health and for marking assignments for this module. Dr Lumsden received a fee as Ibtihal Abdelgadir's supervisor for her MSc Child Health. This is a standard fee for supervision of MSc projects and does not pertain to the Cochrane Review in particular. These activities are unrelated to the Cochrane Review.
Michael P Moncreiff: none known.
Robert S Phillips: none known.
Davinder Singh: none known.
Acknowledgements
We would like to thank Jane Cracknell, the Cochrane Anaesthesia, Critical and Emergency Care Group (ACE) Managing Editor, for assistance with organization of the developing review, and Karen Hovhannisyan, former Trials Search Co‐ordinator, for assistance in identifying search terms for this review. We would like to thank Rodrigo Cavallazzi (Content Editor); Nathan Pace (Statistical Editor); Martin Kryspin Sørensen, Robert F Seal, Subrahmanyan Radhakrishna, and Aaron Donoghue (Peer Reviewers); and Mary Meyers (Consumer Referee) for help and editorial advice provided during preparation of this systematic review.
We would also like to thank Rodrigo Cavallazzi (Content Editor); Vibeke E Horstmann (Statistical Editor); and Subrahmanyan Radhakrishna, Aaron Donoghue, and Martin Kryspin Sørensen (Peer Reviewers) for help and editorial advice provided during preparation of the protocol (Abdelgadir 2014) for this systematic review.
Version history
| Published | Title | Stage | Authors | Version |
| 2017 May 24 | Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates) | Review | Ibtihal S Abdelgadir, Robert S Phillips, Davinder Singh, Michael P Moncreiff, Joanne L Lumsden | |
| 2014 Dec 05 | Video‐laryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates) | Protocol | Ibtihal S Abdelgadir, Robert S Phillips, Michael P Moncreiff, Joanne L Lumsden | |
Differences between protocol and review
We made the following changes to the protocol (Abdelgadir 2014).
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We included children up to 18 years of age, although the protocol upper age limit was 16 years. We did this to keep in line with the upper limit of children age used by studies done in children worldwide.
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We updated the background to accommodate information retrieved from new evidence that has emerged since publication of the protocol.
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We used the term indirect laryngoscopy, or videolaryngoscopy, instead of optical laryngoscopy, as the term 'indirect laryngoscopy' is easier to understand thus avoiding confusion.
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We included human simulated studies as opposed to mannequin‐simulated studies as referred to in the published protocol.
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We added this clarifying sentence to the section on type of participants: These intubations were done in the operating room or in a controlled anaesthetic environment.
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Data were insufficient for review authors to conduct a subgroup analysis according to age groups.
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We used an updated search strategy to cover updated search results for the period 2014‐2017. We did this to gather more sensitive results, as advised by the Cochrane Information Specialist.
Keywords
MeSH
Medical Subject Headings (MeSH) Keywords
Medical Subject Headings Check Words
Adolescent; Child; Child, Preschool; Humans; Infant;
PICOs
Study flow (PRISMA) diagram of included and excluded studies. We reran the search in January 2017. We found three studies of interest. These studies were added to a list of ‘Studies awaiting classification' and will be incorporated into formal review findings during the review update.
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Forest plot of comparison: 1 Indirect/videolaryngoscope versus conventional laryngoscope for intubation of children, outcome: 1.1 Intubation time.
Funnel plot of comparison: 1 Indirect/videolaryngoscope versus conventional laryngoscope for intubation of children, outcome: 1.1 Intubation time.
Funnel plot of comparison: 1 Indirect/videolaryngoscope versus conventional laryngoscope for intubation of children, outcome: 1.4 Successful first intubation attempts.
Comparison 1 Indirect videolaryngoscope vs conventional laryngoscope for intubation of children, Outcome 1 Unsuccessful or more than 2 intubation attempts.
Comparison 1 Indirect videolaryngoscope vs conventional laryngoscope for intubation of children, Outcome 2 Intubation time ‐simulated difficult airway scenario study excluded.
Comparison 1 Indirect videolaryngoscope vs conventional laryngoscope for intubation of children, Outcome 3 Intubation time ‐ nasal intubation study excluded.
Comparison 1 Indirect videolaryngoscope vs conventional laryngoscope for intubation of children, Outcome 4 Successful first intubation attempts.
Comparison 1 Indirect videolaryngoscope vs conventional laryngoscope for intubation of children, Outcome 5 Unsuccessful or more than 2 intubation attempts.
Comparison 1 Indirect videolaryngoscope vs conventional laryngoscope for intubation of children, Outcome 6 Vocal cords score: laryngoscopic view according to the Cormack and Lehane grade (C&L grade) ‐ grade 1 view.
| Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates) | ||||||
| Patient or population: tracheal intubation in children (excluding neonates) | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect | Number of participants | Quality of the evidence | Comments | |
| Risk with direct laryngoscopy | Risk with videolaryngoscopy | |||||
| Intubation time | Mean intubation time in the intervention group was 5.49 seconds higher (1.37 higher to 9.60 higher) | ‐ | 798 | ⊕⊝⊝⊝ | Risk of bias (unblinded), very serious heterogeneity (I2 = 90%), and clinically important increase not excluded | |
| Number of attempts at intubation and unsuccessful intubations | Study population | RR 0.96 | 749 | ⊕⊕⊝⊝ | Very serious heterogeneity (I2 = 67%) | |
| 26 per 1000 | 25 per 1000 | |||||
| Number of attempts at intubation and unsuccessful intubations | Study population | RR 4.93 | 263 | ⊕⊕⊝⊝ | Lack of blinding and no exclusion of a clinically trivial increase | |
| 37 per 1000 | 182 per 1000 | |||||
| Adverse haemodynamic response to endotracheal intubation | In 4 studies that reported occurrences of oxygen saturation < 95%, 5 cases happened in the videolaryngoscopy group and none in the direct laryngoscopy group. The fifth study shows a 97% mean saturation in the video group compared with 99% in the direct group | ‐ | 272 | ⊕⊝⊝⊝ | Very sparse data and serious concerns about unblinded reporting | |
| Adverse haemodynamic response to endotracheal intubation | One study reported a significant increase in heart rate after intubation with direct laryngoscopy, and the other study contradicted this and showed less of a change in heart rate in the direct group. A single study reported that systolic, diastolic, and mean arterial blood pressures were not significantly different between the 2 groups | ‐ | 100 | ⊕⊝⊝⊝ | Very sparse data and serious concerns about unblinded reporting | |
| Other adverse effects of intubation in children, including trauma to oral, pharyngeal, and laryngeal structures, assessed by visual or laryngoscopic examination | Only 2 children from the direct laryngoscopy group were reported to have evidence of trauma as a result of the intubation process compared with no children in the indirect laryngoscopy, or videolaryngoscopy, group | ‐ | 244 | ⊕⊝⊝⊝ | Very sparse data and serious concerns about unblinded reporting | |
| *Risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and relative effect of the intervention (and its 95% CI) | ||||||
| GRADE Working Group grades of evidence | ||||||
| aDowngraded three levels owing to serious concerns about study limitation, inconsistency, and indirectness bDowngraded two levels owing to serious inconsistency and study limitation cDowngraded two levels owing to serious imprecision and study limitation dDowngraded three levels owing to serious imprecision and serious inconsistency and study limitation eDowngraded three levels owing to study limitation and serious imprecision fDowngraded three levels owing to serious imprecision, study limitation, and inconsistency | ||||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Unsuccessful or more than 2 intubation attempts Show forest plot | 12 | 798 | Mean Difference (IV, Random, 95% CI) | 5.49 [1.37, 9.60] |
| 1.1 Other videolaryngoscopes | 4 | 202 | Mean Difference (IV, Random, 95% CI) | 11.04 [4.62, 17.46] |
| 1.2 GlideScope videolaryngoscope | 4 | 403 | Mean Difference (IV, Random, 95% CI) | 5.12 [0.45, 9.80] |
| 1.3 Airtraq videolaryngoscope | 4 | 193 | Mean Difference (IV, Random, 95% CI) | ‐0.81 [‐16.59, 14.96] |
| 2 Intubation time ‐simulated difficult airway scenario study excluded Show forest plot | 11 | 758 | Mean Difference (IV, Random, 95% CI) | 4.20 [0.74, 7.66] |
| 3 Intubation time ‐ nasal intubation study excluded Show forest plot | 11 | 718 | Mean Difference (IV, Random, 95% CI) | 5.43 [1.06, 9.80] |
| 4 Successful first intubation attempts Show forest plot | 11 | 749 | Risk Ratio (M‐H, Random, 95% CI) | 0.96 [0.91, 1.02] |
| 5 Unsuccessful or more than 2 intubation attempts Show forest plot | 5 | 263 | Risk Ratio (M‐H, Random, 95% CI) | 4.93 [1.33, 18.31] |
| 6 Vocal cords score: laryngoscopic view according to the Cormack and Lehane grade (C&L grade) ‐ grade 1 view Show forest plot | 3 | 190 | Risk Ratio (M‐H, Random, 95% CI) | 1.06 [0.93, 1.21] |
