Outcomes Research Consortium, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio.
Division of Multi-Specialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio.
JAMA. 2024 Apr 16;331(15):1279-1286. doi: 10.1001/jama.2024.0762.
Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear.
To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.
DESIGN, SETTING, AND PARTICIPANTS: Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.
Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.
The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries.
Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P < .001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P < .001) with an unadjusted absolute risk difference of -3.7% (95% CI, -4.4% to -3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).
In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.
ClinicalTrials.gov Identifier: NCT04701762.
通常在手术室使用直接喉镜插入气管内导管。已经报道视频喉镜可改善气道可视化；然而，改善可视化是否可减少手术患者的插管尝试尚不清楚。
确定在初始喉镜检查中使用视频喉镜或直接喉镜时，每次手术的插管尝试次数是否更低。
设计、设置和参与者：在美国一家学术医院进行的单中心、集群随机、多次交叉临床试验。患者为年龄在 18 岁或以上的成年人，进行择期或紧急心脏、胸部或血管手术，需要全身麻醉进行单腔气管内插管。患者于 2021 年 3 月 30 日至 2022 年 12 月 31 日入组。基于意向治疗进行数据分析。
将 11 个手术室分为两组，每组以 1 周为周期随机进行超角视频喉镜或直接喉镜进行初始插管尝试。
主要结局为每次手术的手术室插管尝试次数。次要结局为插管失败，定义为负责的临床医生因任何原因在任何时间改用替代喉镜设备，或尝试超过 3 次，以及气道和牙齿损伤的复合结局。
在 7736 名患者的 8429 例手术中，患者的中位年龄为 66（IQR，56-73）岁，35%（2950 例）为女性，85%（7135 例）为择期手术。在随机接受视频喉镜检查的 4413 例手术中有 77 例（1.7%）需要超过 1 次插管尝试，而在随机接受直接喉镜检查的 4016 例手术中有 306 例（7.6%）需要超过 1 次插管尝试，估计插管尝试次数的比例优势比为 0.20（95%CI，0.14-0.28；P<0.001）。在接受视频喉镜检查的 4413 例手术中有 12 例（0.27%）发生插管失败，而在接受直接喉镜检查的 4016 例手术中有 161 例（4.0%）发生插管失败（相对风险，0.06；95%CI，0.03-0.14；P<0.001），未调整的绝对风险差异为-3.7%（95%CI，-4.4%至-3.2%）。气道和牙齿损伤在视频喉镜（41 处损伤[0.93%]）与直接喉镜（42 处损伤[1.1%]）之间无显著差异。
在这项研究中，在美国一家学术医学中心，在需要全身麻醉进行单腔气管内插管的手术成人中，与直接喉镜相比，超角视频喉镜可减少气管插管所需的尝试次数。结果表明，视频喉镜可能是手术患者插管的首选方法。
ClinicalTrials.gov 标识符：NCT04701762。
