Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation

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

doi:10.1002/14651858.CD011136.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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Figure 3

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

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Figure 4

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

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Analysis 1.1

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

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Analysis 2.1

Comparison 2: VLS versus Macintosh, Outcome 1: Hypoxia

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Analysis 3.1

Comparison 3: VLS versus Macintosh, Outcome 1: Mortality

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Analysis 4.1

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

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Analysis 5.1

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

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Analysis 6.1

Comparison 6: VLS versus Macintosh, Outcome 1: Hoarseness

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Analysis 7.1

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

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Analysis 8.1

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

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Analysis 9.1

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

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Analysis 10.1

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

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Analysis 11.1

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

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Analysis 12.1

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

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Analysis 13.1

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

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Analysis 14.1

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

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Analysis 15.1

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

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Analysis 16.1

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

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

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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
	Assumed risk	Corresponding risk
	Direct laryngoscopy	Videolaryngoscopy
Failed intubation	Study population		OR 0.35 (0.19 to 0.65)	4127 (38 studies)	⊕⊕⊕⊝ moderate^a	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 low^a,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 low^a,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 low^a,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)	⊕⊕⊕⊝ moderate^a,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)	⊕⊕⊕⊝ moderate^a,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 low^a,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.

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

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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]

Comparison 1. VLS versus Macintosh

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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]

Comparison 2. VLS versus Macintosh

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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]

Comparison 3. VLS versus Macintosh

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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]

Comparison 4. VLS versus Macintosh

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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]

Comparison 5. VLS versus Macintosh

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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]

Comparison 6. VLS versus Macintosh

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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]

Comparison 7. VLS versus Macintosh

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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]

Comparison 8. VLS versus Macintosh

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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

Comparison 9. VLS versus Macintosh

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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]

Comparison 10. VLS versus Macintosh

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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]

Comparison 11. VLS versus Macintosh

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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]

Comparison 12. VLS versus Macintosh

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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

Comparison 13. VLS versus Macintosh

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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]

Comparison 14. VLS versus Macintosh

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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]

Comparison 15. VLS versus Macintosh

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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]

Comparison 16. VLS versus Macintosh

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