Use of video laryngoscopy (VL) results in improved glottic views, fewer intubation attempts, and higher intubation success in both operating room and emergency department (ED) patients. Less is known about performance characteristics of VL during urgent inpatient intubations performed in other settings. Critical care physicians are increasingly asked to manage airways in hospital settings outside the operating room and ED, and maximizing first-pass success is important since multi-attempt intubations are associated with higher rates of adverse peri-intubation events, including esophageal intubation and hypoxia.
Investigators randomized 117 intensive care unit patients requiring urgent intubation to a first attempt with either GlideScope VL or direct laryngoscopy (DL) performed by critical care fellows with prior training in both methods. Patients with predicted difficult airways or refractory hypoxia were excluded. Patients were sedated with propofol, but neuromuscular blockers were not used.
First-pass success (the primary outcome) was significantly higher with GlideScope VL than DL (74% vs. 40%). Rates of esophageal intubation (7% vs. 0%) and desaturation (8% vs. 4%) did not differ significantly between the DL and VL groups. All unsuccessful DL intubations were rescued with GlideScope VL, 82% on the first attempt.
COMMENT
In this study, critical care fellows performed “urgent intubations” in ICU patients using only propofol sedation and had a higher success rate using the Glidescope compared with direct laryngoscopy. However, the first-pass success rates were poor in both groups (74% vs 40%). Even rescue intubation success rates with a Glidescope yielded only an 82% success rate.
The low success rates are partly related to a sedation-only strategy for endotracheal intubation. Using a neuromuscular blocker in combination with an induction agent as in traditional rapid sequence intubation would likely have yielded much higher rate of intubation success.
Nevertheless, this is just one of many studies that has demonstrated higher first-pass success using the Glidescope over direct laryngoscopy.
