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Cochrane Database of Systematic Reviews

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation

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DOI:
https://doi.org/10.1002/14651858.CD011136.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 15 November 2016see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Anaesthesia Group

Copyright:
  1. Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Sharon R Lewis

    Correspondence to: Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK

    [email protected]

  • Andrew R Butler

    Patient Safety Research Department, Royal Lancaster Infirmary, Lancaster, UK

  • Joshua Parker

    Department of Gastroenterology, Royal Bolton Hospital, Brighton, UK

  • Tim M Cook

    Department of Anaesthesia, Royal United Hospitals Bath NHS Trust, Bath, UK

    University of Bristol, Bristol, UK

  • Andrew F Smith

    Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK

Contributions of authors

Sharon R Lewis (SL), Andrew R Butler (AB), Joshua Parker (JP), Tim M Cook (TC), Andrew F Smith (AS).

Conceiving the review: AS.

Co‐ordinating the review: SL.

Undertaking manual searches: SL.

Screening search results: SL, AB.

Organizing retrieval of papers: SL.

Screening retrieved papers against inclusion criteria: SL, AB.

Appraising quality of papers: SL, AB, JP.

Abstracting data from papers: SL, AB, JP.

Writing to authors of papers for additional information: SL.

Managing data for the review: SL.

Entering data into Review Manager (RevMan 5.3): SL.

Analysing RevMan statistical data: SL.

Interpreting data: SL, AB, AS, TC.

Making statistical inferences: SL, TC, AS.

Writing the review: SL, AB, AS, TC.

Securing funding for the review: AS.

Performing previous work that was the foundation of the present study: N/A

Serving as guarantor for the review (one review author): AS.

Taking responsibility for reading and checking the review before submission: SL.

Sources of support

Internal sources

  • No sources of support provided

External sources

  • NIHR Cochrane Collaboration Programme Grant: Enhancing the safety, quality and productivity of perioperative care. Project Ref: 10/4001/04, UK. This grant funded the work of SRL, AN, AB, AFS and PA performed for this review, UK

Declarations of interest

Sharon R Lewis: see Sources of support.

Andrew R Butler: see Sources of support.

Joshua Parker: none known.

Tim M Cook was paid for lecturing, several years ago (> 36 months), by Intavent Orthofix and the LMA Company. This company manufactures and distributes several supraglottic airway devices and one videolaryngoscope: AP Venner. Dr Cook's department has received free or at cost airway equipment from numerous 'airway' companies for evaluation or research. He and his family have no financial investments and no ownership of any such company of which he is aware. Dr Cook has reported no other conflicts of interest. He spoke at a Storz educational meeting in 2015, and the company paid the costs of travel to this meeting and accommodations. He received no financial benefit from the meeting and was not paid to speak.

Andrew Bulter: See Sources of support.

Andrew F Smith: See Sources of support.

Acknowledgements

We would like to thank Rodrigo Cavallazzi (content editor), Marialena Trivella) (statistical editor), Davide Cattano, Shirley Zhao, Melissa Rethlefsen, Joshua Atkins (peer reviewers), Odie Geiger (consumer referee) for their help and editorial advice during the preparation of this systematic review.

We would also like to thank Rodrigo Cavallazzi (Content Editor); Cathal Walsh (Statistical Editor); and Davide Cattano and Joshua Atkins (Peer Reviewers) for help and editorial advice provided during preparation of the protocol (Lewis 2014) for this systematic review.

We would like to thank Amanda Nicholson, who was an author of the protocol (Lewis 2014) (see Sources of support).

We would like to thank study authors who responded to requests for further study information, in particular, Dr Waleed Riad, Dr Daniel Cordovani and Dr Aki Suzuki.

Version history

Published

Title

Stage

Authors

Version

2022 Apr 04

Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation

Review

Jan Hansel, Andrew M Rogers, Sharon R Lewis, Tim M Cook, Andrew F Smith

https://doi.org/10.1002/14651858.CD011136.pub3

2016 Nov 15

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation

Review

Sharon R Lewis, Andrew R Butler, Joshua Parker, Tim M Cook, Andrew F Smith

https://doi.org/10.1002/14651858.CD011136.pub2

2014 May 28

Videolaryngoscopy versus direct laryngoscopy for adult surgical patients requiring tracheal intubation for general anaesthesia

Protocol

Sharon R Lewis, Amanda Nicholson, Tim M Cook, Andrew F Smith

https://doi.org/10.1002/14651858.CD011136

Differences between protocol and review

We made the following changes to the protocol (Lewis 2014).

Title

We changed the title from "Videolaryngoscopy versus direct laryngoscopy for adult surgical patients requiring tracheal intubation for general anaesthesia" to "Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation" because this better reflects the focus of the review.

Review authors

Amanda Nicholson contributed to the protocol but not to the review.

Objectives

We stated inclusion of participants with a known or predicted difficult airway, which reflected our intended subgroup analysis.

Searching of other resources

We did not contact investigators known to be involved in previous studies to enquire about ongoing or unpublished studies.

Types of outcome measures

We edited the definition of our secondary outcome, serious respiratory complications, which stated "including aspiration" to "pulmonary aspiration of gastric contents and lower respiratory tract infection". This added greater detail to the definition.

Selection of studies; data extraction and management

We did not use paper eligibility and data extraction forms as previously indicated in the protocol. We used on‐line software (www.covidence.org) for this stage of the review.

Measures of treatment effect

We did not collect time‐to‐event data for mortality. Only two studies reported mortality, and we did not combine these results.

Unit of analysis issues

We were not able to amalgamate data into a single pair‐wise comparison without creating a unit of analysis issue. Therefore, we made the decision during the review to include data from the VLS group that would be closest to a result of 'no effect', and to assess this decision in sensitivity analysis.

Dealing with missing data

We did not perform sensitivity analysis for missing data to compare effects of complete case scenario, worst case scenario and last observation carried forward.

Assessment of reporting bias

We did not conduct further assessment of publication bias with the Eggers test.

Effects of interventions

We altered time points for the sore throat outcome to reflect the time points commonly reported in the included studies.

Subgroup analysis and investigation of heterogeneity

We did not carry out subgroup analysis on outcomes other than our primary outcome of failed intubation. We added a sentence to the review to explain how we had defined intubator experience by number of uses.

Summary of findings

We did not include the outcome 'Number of attempts' in the 'Summary of findings table' but replaced it with the outcome 'Proportion of successful first attempts'. We added data for the outcome 'Sore throat'. We altered the definition of hypoxia in the 'Summary of findings table' to match that provided in the 'Primary outcomes' section. We altered the order of outcomes in the 'Summary of findings' section to reflect the order in the sections Types of outcome measures and Effects of interventions.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Study flow diagram.

Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figures and Tables -
Figure 2

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.

Figures and Tables -
Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Funnel plot of comparison: 1 Failed intubation, outcome: 1.1 Failed intubation.

Figures and Tables -
Figure 4

Funnel plot of comparison: 1 Failed intubation, outcome: 1.1 Failed intubation.

Comparison 1: VLS versus Macintosh, Outcome 1: Failed intubation

Figures and Tables -
Analysis 1.1

Comparison 1: VLS versus Macintosh, Outcome 1: Failed intubation

Comparison 2: VLS versus Macintosh, Outcome 1: Hypoxia

Figures and Tables -
Analysis 2.1

Comparison 2: VLS versus Macintosh, Outcome 1: Hypoxia

Comparison 3: VLS versus Macintosh, Outcome 1: Mortality

Figures and Tables -
Analysis 3.1

Comparison 3: VLS versus Macintosh, Outcome 1: Mortality

Comparison 4: VLS versus Macintosh, Outcome 1: Laryngeal/airway trauma

Figures and Tables -
Analysis 4.1

Comparison 4: VLS versus Macintosh, Outcome 1: Laryngeal/airway trauma

Comparison 5: VLS versus Macintosh, Outcome 1: Patient‐reported sore throat

Figures and Tables -
Analysis 5.1

Comparison 5: VLS versus Macintosh, Outcome 1: Patient‐reported sore throat

Comparison 6: VLS versus Macintosh, Outcome 1: Hoarseness

Figures and Tables -
Analysis 6.1

Comparison 6: VLS versus Macintosh, Outcome 1: Hoarseness

Comparison 7: VLS versus Macintosh, Outcome 1: Successful first attempt

Figures and Tables -
Analysis 7.1

Comparison 7: VLS versus Macintosh, Outcome 1: Successful first attempt

Comparison 8: VLS versus Macintosh, Outcome 1: Number of attempts

Figures and Tables -
Analysis 8.1

Comparison 8: VLS versus Macintosh, Outcome 1: Number of attempts

Comparison 9: VLS versus Macintosh, Outcome 1: Time for tracheal intubation

Figures and Tables -
Analysis 9.1

Comparison 9: VLS versus Macintosh, Outcome 1: Time for tracheal intubation

Comparison 10: VLS versus Macintosh, Outcome 1: Intubation difficult score (IDS)

Figures and Tables -
Analysis 10.1

Comparison 10: VLS versus Macintosh, Outcome 1: Intubation difficult score (IDS)

Comparison 11: VLS versus Macintosh, Outcome 1: Improved visualization Cormack & Lehane (CL) 1

Figures and Tables -
Analysis 11.1

Comparison 11: VLS versus Macintosh, Outcome 1: Improved visualization Cormack & Lehane (CL) 1

Comparison 12: VLS versus Macintosh, Outcome 1: Improved visualization Cormack & Lehane (CL) 1 to 4

Figures and Tables -
Analysis 12.1

Comparison 12: VLS versus Macintosh, Outcome 1: Improved visualization Cormack & Lehane (CL) 1 to 4

Comparison 13: VLS versus Macintosh, Outcome 1: Improved visualization POGO

Figures and Tables -
Analysis 13.1

Comparison 13: VLS versus Macintosh, Outcome 1: Improved visualization POGO

Comparison 14: VLS versus Macintosh, Outcome 1: Failed intubation by scope

Figures and Tables -
Analysis 14.1

Comparison 14: VLS versus Macintosh, Outcome 1: Failed intubation by scope

Comparison 15: VLS versus Macintosh, Outcome 1: Failed intubation by airway difficulty

Figures and Tables -
Analysis 15.1

Comparison 15: VLS versus Macintosh, Outcome 1: Failed intubation by airway difficulty

Comparison 16: VLS versus Macintosh, Outcome 1: Failed intubation by experience of personnel

Figures and Tables -
Analysis 16.1

Comparison 16: VLS versus Macintosh, Outcome 1: Failed intubation by experience of personnel

Summary of findings 1. Videolaryngoscopy compared with direct laryngoscopy for tracheal intubation

Videolaryngoscopy compared with direct laryngoscopy for tracheal intubation

Patient or population: patients requiring tracheal intubation
Settings: clinical, emergency or out‐of‐hospital, worldwide
Intervention: videolaryngoscopy
Comparison: direct laryngoscopy

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Direct laryngoscopy

Videolaryngoscopy

Failed intubation

Study population

OR 0.35
(0.19 to 0.65)

4127
(38 studies)

⊕⊕⊕⊝
moderatea

Downgraded by 1 level. See footnote.

94 per 1000

35 per 1000
(19 to 63)

Moderate

Hypoxia

Study population

OR 0.39
(0.1 to 1.44)

1319
(8 studies)

⊕⊝⊝⊝
very lowa,b,c

Downgraded by 3 levels. See footnotes.

58 per 1000

23 per 1000
(6 to 81)

Moderate

Serious respiratory complications

See comment

See comment

Not estimable

78
(1 study)

⊕⊝⊝⊝
very lowa,d

Insufficient data to complete meta‐analysis. Downgraded by 2 levels. See footnotes.

Mortality

Study population

OR 1.09
(0.65 to 1.82)

663
(2 studies)

⊕⊝⊝⊝
very lowa,e,f,g

Downgraded by 3 levels. See footnotes.

106 per 1000

114 per 1000
(71 to 177)

Very low

Proportion of successful first attempts

Study population

OR 0.79
(0.48 to 1.3)

4731
(36 studies)

⊕⊕⊕⊝
moderatea,h

Downgraded by 1 level. See footnotes.

831 per 1000

795 per 1000
(702 to 865)

Moderate

Sore throat

Study population

OR 1.00
(0.73 to 1.38)

1548
(10 studies)

⊕⊕⊕⊝
moderatea,i

Downgraded by 1 level. See footnotes.

250 per 1000

289 per 1000
(211 to 385)

Moderate

Time for tracheal intubation

See comment

See comment

Not estimable

4488
(37 studies)

⊕⊝⊝⊝
very lowa,j

High level of statistical heterogeneity between studies; therefore meta‐analysis not completed. Downgraded by 3 levels. See footnotes.

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI = confidence interval; OR = odds ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

aNot possible to blind intubator to device. Downgraded for study limitations.
bI2 statistic shows high level of heterogeneity at 70%. Downgraded for inconsistency.
cOnly three studies with event data. Downgraded for imprecision.
dOnly one study. Downgraded for imprecision.
eOnly two studies with event data. Downgraded for imprecision.
fBoth studies include only trauma patients.
gNo assessment of publication bias made for this outcome.
hI2 statistic shows high level of heterogeneity at 79%. Downgraded for inconsistency.
iI2 statistic shows moderate level of heterogeneity at 55%. Downgraded for inconsistency.
jI2 statistic shows very high level of heterogeneity at 96%. Downgraded for inconsistency.

Figures and Tables -
Summary of findings 1. Videolaryngoscopy compared with direct laryngoscopy for tracheal intubation
Comparison 1. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Failed intubation Show forest plot

38

4127

Odds Ratio (M‐H, Random, 95% CI)

0.35 [0.19, 0.65]

Figures and Tables -
Comparison 1. VLS versus Macintosh
Comparison 2. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Hypoxia Show forest plot

8

1319

Odds Ratio (M‐H, Random, 95% CI)

0.39 [0.10, 1.44]

Figures and Tables -
Comparison 2. VLS versus Macintosh
Comparison 3. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Mortality Show forest plot

2

663

Odds Ratio (M‐H, Fixed, 95% CI)

1.09 [0.65, 1.82]

Figures and Tables -
Comparison 3. VLS versus Macintosh
Comparison 4. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Laryngeal/airway trauma Show forest plot

29

3110

Odds Ratio (M‐H, Random, 95% CI)

0.68 [0.48, 0.96]

Figures and Tables -
Comparison 4. VLS versus Macintosh
Comparison 5. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

5.1 Patient‐reported sore throat Show forest plot

17

2392

Odds Ratio (M‐H, Random, 95% CI)

0.82 [0.56, 1.19]

5.1.1 Postanaesthesia care unit

10

1548

Odds Ratio (M‐H, Random, 95% CI)

1.00 [0.73, 1.38]

5.1.2 Postoperative day 1

8

844

Odds Ratio (M‐H, Random, 95% CI)

0.54 [0.27, 1.07]

Figures and Tables -
Comparison 5. VLS versus Macintosh
Comparison 6. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

6.1 Hoarseness Show forest plot

6

527

Odds Ratio (M‐H, Fixed, 95% CI)

0.57 [0.36, 0.88]

Figures and Tables -
Comparison 6. VLS versus Macintosh
Comparison 7. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

7.1 Successful first attempt Show forest plot

36

4731

Odds Ratio (M‐H, Random, 95% CI)

1.27 [0.77, 2.09]

Figures and Tables -
Comparison 7. VLS versus Macintosh
Comparison 8. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

8.1 Number of attempts Show forest plot

28

6692

Odds Ratio (M‐H, Random, 95% CI)

1.06 [0.68, 1.66]

8.1.1 1 attempt

28

3346

Odds Ratio (M‐H, Random, 95% CI)

1.25 [0.68, 2.31]

8.1.2 2 to 4 attempts

28

3346

Odds Ratio (M‐H, Random, 95% CI)

0.89 [0.47, 1.70]

Figures and Tables -
Comparison 8. VLS versus Macintosh
Comparison 9. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

9.1 Time for tracheal intubation Show forest plot

37

Mean Difference (IV, Random, 95% CI)

Subtotals only

Figures and Tables -
Comparison 9. VLS versus Macintosh
Comparison 10. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

10.1 Intubation difficult score (IDS) Show forest plot

7

568

Odds Ratio (M‐H, Random, 95% CI)

7.13 [3.12, 16.31]

Figures and Tables -
Comparison 10. VLS versus Macintosh
Comparison 11. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

11.1 Improved visualization Cormack & Lehane (CL) 1 Show forest plot

22

2240

Odds Ratio (M‐H, Random, 95% CI)

6.77 [4.17, 10.98]

Figures and Tables -
Comparison 11. VLS versus Macintosh
Comparison 12. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

12.1 Improved visualization Cormack & Lehane (CL) 1 to 4 Show forest plot

22

4480

Odds Ratio (M‐H, Random, 95% CI)

1.00 [0.54, 1.87]

12.1.1 CL 1 to 2

22

2240

Odds Ratio (M‐H, Random, 95% CI)

5.42 [3.70, 7.95]

12.1.2 CL 3 to 4

22

2240

Odds Ratio (M‐H, Random, 95% CI)

0.18 [0.13, 0.27]

Figures and Tables -
Comparison 12. VLS versus Macintosh
Comparison 13. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

13.1 Improved visualization POGO Show forest plot

4

Mean Difference (IV, Random, 95% CI)

Totals not selected

Figures and Tables -
Comparison 13. VLS versus Macintosh
Comparison 14. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

14.1 Failed intubation by scope Show forest plot

33

3916

Odds Ratio (M‐H, Random, 95% CI)

0.40 [0.21, 0.75]

14.1.1 GlideScope

16

1306

Odds Ratio (M‐H, Random, 95% CI)

0.57 [0.25, 1.32]

14.1.2 Pentax AWS

11

1086

Odds Ratio (M‐H, Random, 95% CI)

0.24 [0.05, 1.20]

14.1.3 McGrath

5

466

Odds Ratio (M‐H, Random, 95% CI)

1.18 [0.06, 23.92]

14.1.4 C‐MAC

8

1058

Odds Ratio (M‐H, Random, 95% CI)

0.32 [0.15, 0.68]

Figures and Tables -
Comparison 14. VLS versus Macintosh
Comparison 15. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

15.1 Failed intubation by airway difficulty Show forest plot

34

3383

Odds Ratio (M‐H, Random, 95% CI)

0.35 [0.18, 0.65]

15.1.1 Predicted not difficult

19

1743

Odds Ratio (M‐H, Random, 95% CI)

0.61 [0.22, 1.67]

15.1.2 Predicted difficult

6

830

Odds Ratio (M‐H, Random, 95% CI)

0.28 [0.15, 0.55]

15.1.3 Simulated difficult

9

810

Odds Ratio (M‐H, Random, 95% CI)

0.18 [0.04, 0.77]

Figures and Tables -
Comparison 15. VLS versus Macintosh
Comparison 16. VLS versus Macintosh

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

16.1 Failed intubation by experience of personnel Show forest plot

22

2273

Odds Ratio (M‐H, Random, 95% CI)

0.29 [0.13, 0.67]

16.1.1 Personnel experienced with both devices

17

1927

Odds Ratio (M‐H, Random, 95% CI)

0.32 [0.13, 0.75]

16.1.2 Personnel less experienced with VLS

5

346

Odds Ratio (M‐H, Random, 95% CI)

0.20 [0.02, 2.56]

Figures and Tables -
Comparison 16. VLS versus Macintosh