title: Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial.
abstract: 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.
  
  
  
  To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients.
  
  
  
  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.
  
  
  
  Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia.
  
  
  
  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.
  
  
  
  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).
  
  
  
  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.
  
  
  
  clinicaltrials.gov Identifier: NCT02413723.
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France.
authors.forename: Jean Baptiste
authors.initials: JB
authors.lastname: Lascarrou
authors.affiliation: 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.
authors.forename: Julie
authors.initials: J
authors.lastname: Boisrame-Helms
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France.
authors.forename: Arthur
authors.initials: A
authors.lastname: Bailly
authors.affiliation: Clinical Research Unit, District Hospital Centre, La Roche-sur-Yon, France5Delegation a la Recherche Clinique et a l'Innovation-CHU Hotel Dieu, Nantes, France.
authors.forename: Aurelie
authors.initials: A
authors.lastname: Le Thuaut
authors.affiliation: Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France.
authors.forename: Toufik
authors.initials: T
authors.lastname: Kamel
authors.affiliation: Medical Intensive Care Unit, University Hospital Centre, Tours, France.
authors.forename: Emmanuelle
authors.initials: E
authors.lastname: Mercier
authors.affiliation: AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France.
authors.forename: Jean-Damien
authors.initials: JD
authors.lastname: Ricard
authors.affiliation: APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France.
authors.forename: Virginie
authors.initials: V
authors.lastname: Lemiale
authors.affiliation: Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France.
authors.forename: Gwenhael
authors.initials: G
authors.lastname: Colin
authors.affiliation: Medical Intensive Care Unit, Cochin University Hospital Centre, Paris, France.
authors.forename: Jean Paul
authors.initials: JP
authors.lastname: Mira
authors.affiliation: 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.
authors.forename: Ferhat
authors.initials: F
authors.lastname: Meziani
authors.affiliation: AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Messika
authors.affiliation: Medical Intensive Care Unit, University Hospital Centre, Tours, France.
authors.forename: Pierre Francois
authors.initials: PF
authors.lastname: Dequin
authors.affiliation: Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Boulain
authors.affiliation: APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France.
authors.forename: Elie
authors.initials: E
authors.lastname: Azoulay
authors.affiliation: Medical Intensive Care Unit, Cochin University Hospital Centre, Paris, France.
authors.forename: Benoit
authors.initials: B
authors.lastname: Champigneulle
authors.affiliation: Medical Intensive Care Unit, University Hospital Centre, Nantes, France13EA 3826, Clinical and Experimental Treatments for Infections, University of Medicine, Nantes, France.
authors.forename: Jean
authors.initials: J
authors.lastname: Reignier
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D057194:Intention to Treat Analysis; D007442:Intubation, Intratracheal / Q000295:instrumentation / Q000379:methods* / Q000706:statistics & numerical data; D020704:Laryngoscopes; D007828:Laryngoscopy / Q000295:instrumentation / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D018401:Sample Size; D017211:Treatment Failure