Avoidance Versus Use of Neuromuscular Blocking Agents for Optimising Video Laryngoscopy‐Assisted Tracheal Intubation—A Systematic Review With Meta‐Analysis and Trial Sequential Analysis

Background Tracheal intubation during anaesthesia carries risks, and difficult intubation can lead to severe complications. Neuromuscular blocking agents (NMBAs) are widely recommended to improve intubation conditions, but they have potential adverse effects. Video laryngoscopy is widely used, yet evidence on the role of NMBAs in this setting is sparse. We aimed to assess whether avoidance versus use of NMBAs affects first‐pass success and intubation conditions during video laryngoscopy in adults. Method Randomised controlled trials ( RCTs ) comparing avoidance versus use of NMBAs for tracheal intubation in adults during video laryngoscopy were included. The primary outcome was failed first‐pass intubation, as defined by the individual trials. Secondary outcomes were failed intubation, adverse effects ( AEs ) and serious adverse effects ( SAEs ), and acceptable intubation conditions. Furthermore, trial sequential analysis ( TSA ) was undertaken. Results 9483 records were screened. Eight RCTs (744 participants) met the inclusion criteria. The primary outcome was extractable from seven trials (690 participants). Individual trial estimates showed either no clear effect or an increased risk of failed first‐pass intubation when NMBAs were avoided. We found a statistically non‐significant RR: 1.81 (95% CI: 0.93–3.55, p = 0.08, Cochran's Q = 12.0, p = 0.04, I 2 = 58%, D 2 = 74%, TSA adjusted RR: 1.77, TSA adjusted 95% CI: 0.48–6.50, GRADE = very low certainty of evidence) comparing avoidance versus use of NMBAs. TSA showed that the trial sequential monitoring boundaries were not crossed, and the required information size of 2334 was not achieved. Conclusion The effect of avoidance of NMBAs for facilitating video laryngoscopy‐assisted tracheal intubation in adult patients is uncertain (very low certainty), and the required information size was not reached. Editorial Comment This systematic review assessed trial evidence concerning whether or not muscle relaxant use is related to first pass failure in intubation attempts using video laryngoscopy. Evidence to date does not support a clear conclusion on whether avoidance of muscle relaxants in this context is beneficial or not, at least for first pass intubation success, though the evidence has very low certainty for this question.