Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients

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.