Video versus direct laryngoscopy for urgent tracheal intubation in neonates: a systematic review and meta-analysis

Background Adults and children are most often intubated by anesthetists in controlled conditions. In contrast, newborn intubations are performed by neonatologists and paediatricians, in urgent circumstances within the NICU and delivery room (DR). Neonatal intubation is a difficult skill to learn and maintain, involving correctly identifying airway anatomy. Success rates, in NICU and DR are around 50% using direct laryngoscopy (DL), with a lower success rate in junior intubators. Video laryngoscopy (VL) uses a camera on the tip of blade, allowing real time images to be displayed on screen, with this coaching and technique adjustment can be done. A lower number of intubation opportunities has been seen in recent years, making it difficult to achieve proficiency, anesthetic literature suggests that over 40 intubations are necessary for this. A recent Cochrane review4 included studies where intubations were attempted by anesthetists in operating theatres, where success rates are higher. VL is increasingly used in paediatric and adult practice.

Objective To compare of the efficacy and safety of VL and DL, for intubation of neonates within NICU and DR.

Design/Methods We searched CENTRAL, MEDLINE, EMBASE and CINAHL databases, for randomised and quasi-randomised trials that compared VL to DL in neonates, up to August 2024. We excluded studies conducted in the operating theatre. We used Cochrane methodology and RevMan. We extracted and analysed data from the eligible studies and assessed their risk of bias [1] [2] [3] [4] [5] [6] [7].

Results Six studies (O&apos;Shea 2015, Moussa 2016, Volz 2018, Bartle 2019, Tippman 2023 and Geraghty 2024) met our inclusion criteria, with a combined total of 863 intubations. Success at first intubation attempt was reported in four studies. VL increased first pass success rate compared to DL (RR 1.46, 95% CI 1.27-1.68), with NNT 6. An increase in overall success rate, was shown to be statistically significant by Volz and Moussa (VL 57% vs DL 33% p<0.05 and VL 75% vs DL 63% p 0.03). There was no difference in the incidence of desaturation or bradycardia and mucosal trauma was similar between the VL and DL groups. Subgroup analysis showed an increased first pass success rate in trainees (RR 1.5, 95% CI 1.3-1.74), with NNT 5.

Conclusion(s) The use of VL in NICU and DR, produces a significant improvement in first pass success rate for neonatal intubation, without an increase in adverse events. A significant increase in first pass success rates in trainees was also found. VL should be the standard of care for neonatal intubation, including in inexperienced intubators.

Publikationsverlauf

Artikel online veröffentlicht:
19. Mai 2025

• Literatur

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