First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial
Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, et al. Lancet. 2020;396(10266):1905-1913.
Tracheal intubations in children are not common in emergency medicine, but when they occur, they can be highly stressful events, probably because of a lack of practice among most physicians.
Maximizing the chance of first-pass success is important, because multiple attempts can be associated with an increased risk of complications, including neurologic injury, cardiac arrest, and death.
The traditional teaching is to use a Miller blade in infants, but we have reviewed some recent articles questioning this method as the true “gold standard.” Should we perhaps be using video laryngoscopy (VL)?
This is an RCT conducted in the OR (not the ED) from hospitals in the United States and Australia. The study enrolled children <12 months of age undergoing a noncardiac procedure lasting longer than 30 minutes, and requiring general anesthesia and orotracheal intubation by an anesthesiologist.
A total of 564 infants were randomized 1:1 to standard VL (Storz C-Mac Miller video laryngoscope) or direct laryngoscopy (DL) with either a Miller or a Macintosh 2 blade.
A total of 99% of the VL intubations were performed with a Miller blade, and 89% of the DL intubations were performed with a straight blade (almost all Miller, but a few with another type called a Hipple).
First-pass success was found in 93% of the VL group vs 88% of the DL group.
In a post hoc subgroup analysis, the authors found a larger benefit of VL in smaller children (<6.5 kg).
The time to successful intubation was >1 minute for 15% of the VL group vs 10% of the DL group.
Complications were very rare overall. The most notable complication was the rate of esophageal intubations (<1% with VL vs 3% with DL).
This is an overall well-done study whose main limitations are not related to the design or execution itself but to potential generalizability to the ED setting. Whether these findings would hold true during an emergency airway in which the child has not been adequately prepared or in whom blood or secretions might affect the view on a VL is unknown. In addition, most ED physicians have not been trained to perform VL in infants and may not be comfortable with, or have access to, a video laryngoscope with a Miller-like blade.
EDITOR’S COMMENTARY: In this international multicenter trial, the authors found a 5% increase in first-pass success and decreased rates of esophageal intubation when using VL compared with DL in infants <1 year old. The clinical impact of this difference is not known, and care needs to be taken in generalizing the findings of this OR-based study to the ED, where familiarity with VL in kids is likely to be a lot lower. The popularity of VL is increasing rapidly. It seems worth it to me to at least familiarize yourself with VL in infants as a backup, if nothing else.
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