Jean Baptiste Lascarrou1, Julie Boisrame-Helms2, Arthur Bailly1, Aurelie Le Thuaut3, Toufik Kamel4, Emmanuelle Mercier5, Jean-Damien Ricard6, Virginie Lemiale7, Gwenhael Colin1, Jean Paul Mira8, Ferhat Meziani2, Jonathan Messika6, Pierre Francois Dequin5, Thierry Boulain4, Elie Azoulay7, Benoit Champigneulle8, Jean Reignier9. 1. Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France. 2. Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France3EA 7293, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine, Université de Strasbourg, Strasbourg, France. 3. Clinical Research Unit, District Hospital Centre, La Roche-sur-Yon, France5Delegation a la Recherche Clinique et a l'Innovation-CHU Hotel Dieu, Nantes, France. 4. Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France. 5. Medical Intensive Care Unit, University Hospital Centre, Tours, France. 6. AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France. 7. APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France. 8. Medical Intensive Care Unit, Cochin University Hospital Centre, Paris, France. 9. Medical Intensive Care Unit, University Hospital Centre, Nantes, France13EA 3826, Clinical and Experimental Treatments for Infections, University of Medicine, Nantes, France.
Abstract
Importance: In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. Objective: To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. Design, Setting, and Participants: Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up. Interventions: Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia. Main Outcomes and Measures: The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications. Results: Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, -2.5% [95% CI, -11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, -6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, -2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, -2.3% [95% CI, -7.4% to 2.8%]; P = .37). Conclusions and Relevance: Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels. Trial Registration: clinicaltrials.gov Identifier: NCT02413723.
RCT Entities:
Importance: In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopy may decrease this risk by improving glottis visualization. Objective: To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. Design, Setting, and Participants: Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up. Interventions: Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia. Main Outcomes and Measures: The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications. Results: Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, -2.5% [95% CI, -11.9% to 6.9%]; P = .60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, -6.3% to 8.6%]; P = .76). The median time to successful intubation was 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P = .95). Video laryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, -2.7% to 10.4%]; P = .25). In post hoc analysis, video laryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; P = .01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, -2.3% [95% CI, -7.4% to 2.8%]; P = .37). Conclusions and Relevance: Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels. Trial Registration: clinicaltrials.gov Identifier: NCT02413723.
Authors: Samir Jaber; Giacomo Bellani; Lluis Blanch; Alexandre Demoule; Andrés Esteban; Luciano Gattinoni; Claude Guérin; Nicholas Hill; John G Laffey; Salvatore Maurizio Maggiore; Jordi Mancebo; Paul H Mayo; Jarrod M Mosier; Paolo Navalesi; Michael Quintel; Jean Louis Vincent; John J Marini Journal: Intensive Care Med Date: 2017-08-07 Impact factor: 17.440
Authors: David R Janz; Jonathan D Casey; Matthew W Semler; Derek W Russell; James Dargin; Derek J Vonderhaar; Kevin M Dischert; Jason R West; Susan Stempek; Joanne Wozniak; Nicholas Caputo; Brent E Heideman; Aline N Zouk; Swati Gulati; William S Stigler; Itay Bentov; Aaron M Joffe; Todd W Rice Journal: Lancet Respir Med Date: 2019-10-01 Impact factor: 30.700