Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. (Patel)

Janz DR, et al. Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. Crit Care Med. 2016 Nov;44(11):1980-1987.

OBJECTIVE: To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

DESIGN: A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

SETTING: Medical ICU in a tertiary, academic medical center.

PATIENTS: Critically ill patients 18 years old or older.

INTERVENTIONS: Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS: Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator’s previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

CONCLUSIONS: In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Dexmedetomidine, the ideal drug for attenuating the pressor response. (Pham)

Abstract: Laryngoscopy and endotracheal intubation is often associated with hypertension and tachycardia because of the sympathoadrenal stimulation which is usually transient and lasts for 5-10 minutes. In patients with cardiovascular and cerebrovascular disease, this sudden rise in Heart Rate (HR) and blood pressure can produce deleterious effects in the form of myocardial ischemia, pulmonary edema and cerebral hemorrhage. Many methods have been tried to obtund the haemodynamic response in adult and pediatric patients, but none proved to be ideal. Dexmedetomidine has been particularly effective in blunting the haemodynamic response to laryngoscopy and tracheal intubation.

Aims: To study the efficacy of 0.6 μg/kg dexmedetomidine IV, given 10 minutes (min) before induction to obtund the pressor response of laryngoscopy and tracheal intubation.

Methods: 100 normotensive patients aged 14-55 years old were assigned randomly into two groups. 10 min before induction these two groups received, group C (n=50): received 10 ml normal saline (NS) IV over 10 min, group D (n=50): received dexmedetomidine 0.6μg/kg body weight diluted to 10 ml NS IV over 10 min. After induction of anaesthesia, HR, SBP, DBP and MAP were recorded at various time intervals like before induction, after induction and 1, 3, 5 and 10 min after laryngoscopy and intubation.

Results: It was noted that in group C, following laryngoscopy and intubation, the mean rise in HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) were found to be 36.24 bpm, 30.02 mmHg, 22.34 mmHg and 26.42 mmHg respectively, one minute after intubation. In group D, the mean of HR, SBP, DBP and MAP were decreased by 2.86 bpm, 15.86 mmHg, 9.54 mmHg and 1.98 mmHg respectively compared to basal values which was statistically highly significant (p=0.000). In addition dexmedetomidine reduces the requirement of thiopentone and vecuronium bromide and produces arousable sedation after extubation with minimal incidence of bradycardia and hypotension.

Conclusions: Dexmedetomidine (0.6μg/kg) IV, given 10 min before induction was seen to effectively attenuate the pressor response to laryngoscopy and tracheal intubation without any side effect.

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The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. (Chandler)

Anesth Analg. 2013 Jul;117(1):144-9. PMID: 23687228

BACKGROUND: The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators.

METHODS: We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension.

RESULTS: There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL.

CONCLUSIONS: UEI using a VL as the primary device improved intubation success and decreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.

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