Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates

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Authors

Krithika Lingappan1, Jennifer L Arnold2, Thomas L Shaw3, Caraciolo J Fernandes4, Mohan Pammi4

Background - Methods - Results - Characteristics of Included Studies - References - Data Tables and Graphs


1Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA [top]
2Department of Neonatology, Baylor College of Medicine; Texas Children's Hospital, Houston, TX, USA [top]
3Departments of Anesthesiology and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA [top]
4Section of Neonatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA [top]

Citation example: Lingappan K, Arnold JL, Shaw TL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD009975. DOI: 10.1002/14651858.CD009975.pub2. [top]

Contact person

Mohan Pammi

Section of Neonatology, Department of Pediatrics
Baylor College of Medicine
6621, Fannin, MC.WT 6-104
Houston TX 77030
USA

E-mail: mohanv@bcm.tmc.edu

Dates

Assessed as Up-to-date:30 May 2013
Date of Search:30 May 2013
Next Stage Expected:30 May 2015
Protocol First Published:Issue 7, 2012
Review First Published:Issue 2, 2015
Last Citation Issue:Issue 2, 2015

Abstract

Background

Establishment of secure airway is a critical part of neonatal resuscitation both in the delivery room and in the neonatal unit. Videolaryngoscopy is a new technique that has the potential to facilitate successful endotracheal intubation and decrease adverse consequences of delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates.

Objectives

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required and increasing the success rate for endotracheal intubation in neonates.

Search methods

We used the search strategy of the Cochrane Neonatal Review Group. We searched for randomized controlled trials evaluating videolaryngoscopy for neonatal endotracheal intubation in May 2013 in the electronic databases; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; CINAHL; abstracts of the Pediatric Academic Societies; websites for registered trials at www.clinicaltrials.gov and www.controlled-trials.com External Web Site Policy; and in the reference lists of relevant studies.

Selection criteria

Randomized or quasi-randomized trials in neonates evaluating videolaryngoscopy for endotracheal intubation compared with direct laryngoscopy.

Data collection and analysis

Review authors performed data collection and analysis as recommended by the Cochrane Neonatal Review Group. Two review authors (KL and MP) independently assessed studies identified by the search strategy for inclusion.

Main results

Our search strategy performed in May 2013 yielded 7057 references. Two review authors (MP and KL) independently assessed all references for inclusion. We did not find any completed studies for inclusion but identified three ongoing trials and one study awaiting classification.

Authors' conclusions

There was insufficient evidence to recommend or refute the use of videolaryngoscopy for endotracheal intubation in neonates. Well-designed, adequately powered randomized controlled studies are necessary to address efficacy and safety of videolaryngoscopy for endotracheal intubation in neonates.

Plain language summary

The use of video devices in assisting the placement of breathing tube in babies

 

Background

One in a 100 newborn may need placement of breathing tube (intubation) for survival. Video-assisted placement of the breathing tube may be easier than a standard approach.

Study characteristics

In this review, we sought evidence for the usefulness of these video-assisted devices for the placement of breathing tubes in babies. We searched scientific databases for clinical trials of babies who needed intubation in the delivery room, operating room or intensive care unit. The studies could measure time to intubation, number of attempts at intubation or success rate of first intubation. The evidence is current to May 2013.

Key results and quality of the evidence

We found no clinical studies that met our selection criteria. We make a case for further research in evaluating the use of video-assisted devices in the placement of breathing tubes in newborns.

Background

Description of the condition

Endotracheal intubation is a life-saving procedure performed in neonates in many clinical situations. Preterm birth, birth asphyxia, respiratory failure, meconium aspiration and respiratory problems including congenital anatomic abnormalities of the airway may require rapid and immediate endotracheal intubation to secure the airway, optimize oxygenation and achieve adequate ventilation. Successful intubation requires adequate visualization of the airway and related structures. Improved visibility may avoid prolonged or repeated intubation attempts. Several aspects of the anatomy of the neonatal airway, including the small size of the mouth and airway; the disproportionately large tongue, epiglottis and arytenoids; extensive secretions; and the keyhole appearance of the glottis, further complicate the process of intubation. The limited visibility often makes it difficult to train junior colleagues in the technique of neonatal endotracheal intubation. Supervisors of intubation training rely mainly on the feedback from the trainee rather than by visual confirmation. In addition, low pulmonary reserve and high oxygen consumption in small infants limit the time for instruction and correction during direct laryngoscopy. Thus, the instructors often cannot recognize the trainee's problem and have to perform the tracheal intubation themselves. This delays learning and achievement of proficiency in tracheal intubation for the trainee (Weiss 2001). Videolaryngoscopy can assist both the trainer and the trainee in identifying anatomical structures in the airway and enhance the success of intubation (Vanderhal 2009).

Description of the intervention

Direct laryngoscopy using the appropriate sized Miller straight or the Macintosh laryngoscope blade relies on the achievement of direct line of sight between the intubator and the glottis of the neonate and is the standard procedure for neonatal endotracheal intubation. Videolaryngoscopy is a form of indirect laryngoscopy in which the clinician does not directly view the larynx but the laryngeal visualization is performed with a fiberoptic or digital laryngoscope inserted transnasally or transorally (Pott 2008). These devices possess high-resolution micro cameras and video monitors, which improve the view of the laryngeal inlet independent of the line of sight. Videolaryngoscopic techniques have been widely used in adult endotracheal intubation, and a variety of video-based devices has been developed. Technological advances have allowed a miniaturized device to be used in neonates. In this review, we intended to compare direct laryngoscopy with videolaryngoscopy for endotracheal intubation in neonates.

Videolaryngoscopes can be classified as follows: integrated channel laryngoscopes (CTrach, Pentax, Airtaq), laryngoscopes with video stylets (Bonfils) and rigid blade laryngoscopes (C-MAC, GlideScope, Truview EVO2) (Healy 2012). There have been many adult and pediatric trials with these devices. The GlideScope allows for superior laryngeal visualization in both routine and difficult airways in adults without the need for direct line of sight (Xue 2006), which facilitates faster learning when compared with the Macintosh laryngoscope (Lim 2005). One randomized controlled trial of 203 pediatric participants, that compared GlideScope with direct laryngoscopy found that GlideScope provided a laryngoscopic view equal to or better than that of direct laryngoscopy but required a longer time for intubation (Kim 2008). The McGrath videolaryngoscope had a success rate of 98% in 147 adults (Shippey 2007), and provided improved laryngeal views in participants with known difficult airways (Shippey 2008). Similarly, the Pentax airway scope enables even the less experienced operators to obtain an optimal view (Asai 2008), and faster and more successful intubation on first attempt for novices when compared with the Macintosh device (Hirabayashi 2007; Hirabayashi 2008).

In one meta-analysis of adult studies on videolaryngoscopy (Griesdale 2012), there was no difference between the videolaryngoscope (GlideScope) and direct laryngoscope regarding successful first-attempt intubation or time to intubation. In the same review, in two studies examining non-experts, successful first-attempt intubation (risk ratio (RR) 1.8, 95% confidence interval (CI) 1.4 to 2.4) and time to intubation (mean difference (MD) -43 seconds, 95% CI -72 to -14) were improved using the GlideScope. These benefits were not seen with intubation experts. The videolaryngoscope provided improved glottic visualization, particularly in people with potential or simulated difficult airways. One study evaluated the C-MAC videolaryngoscope in adults and found that a diverse group of anesthesia providers achieved a higher intubation success rate on first attempt with the C-MAC in people with predictors of difficult intubation (Aziz 2012). Pediatric studies reported time to intubation, number of intubation attempts, adverse effects of the laryngoscopic procedure and the view of the airway (Fiadjoe 2012; Singh 2009; Vlatten 2009). Time required for successful intubation was significantly longer in the videolaryngoscopy group compared with the direct laryngoscopy group. There was no difference in the number of intubation attempts between the two groups. Airway trauma (minor gum bleeds) was reported only in the direct laryngoscopy group in one study (Singh 2009), and not observed in the other studies (Fiadjoe 2012; Vlatten 2009). Better visualization of the airway with the videolaryngoscope was reported in these studies (Fiadjoe 2012; Singh 2009; Vlatten 2009).

Videolaryngoscopes are portable and can be used in both the delivery room and the neonatal intensive care unit (NICU) for neonates requiring endotracheal intubation. Videolaryngoscopes will be especially useful for neonates in whom a difficult airway is anticipated, for example in Pierre-Robin sequence, oral or neck masses, cleft palate, pharyngeal perforation and subglottic stenosis. One preliminary report by Vanderhal et al., in 47 infants weighing between 530 g and 6795 g using the Kaplan-Berci videolaryngoscope, showed promise for the use of this new technique to improve airway management, evaluation and teaching (Vanderhal 2009). Significant differences exist between videolaryngoscopy and direct laryngoscopy in terms of the airway view obtained and the technique needed to insert the endotracheal tube (ETT) into the trachea. These differences may necessitate appropriate training curricula for videolaryngoscopy compared with direct laryngoscopic intubation. Improper advancement of the videolaryngoscope may cause laceration of the soft palate or the palatoglossal arch.

How the intervention might work

Intubation is a common life-saving procedure in the NICU. It may be performed emergently in the delivery room or NICU or non-urgently as in neonates going for surgery or for surfactant administration. The intubation may be attempted by trainees with varying degrees of skill and experience and the neonates may have airway or facial abnormalities that may make the procedure more challenging than usual. Direct laryngoscopic tracheal intubation in neonates is an important but sometimes difficult skill to master that requires regular practice to maintain. The limited literature reviewing research in intubation success for trainees in pediatrics suggests that this vital skill needs to be reinforced (Falck 2003; Roberts 2006). The number of episodes that pediatric residents have for neonatal intubation has been decreasing due to several reasons including decreased time for residents in the NICU with varying patient acuity, duty hours restrictions and competition with other learners (nurse practitioners, respiratory therapists) who need to intubate to maintain their own skills. Successful direct laryngoscopy requires alignment of the oral, pharyngeal and laryngeal axes so that the vocal cords can be visualized (Thong 2009). The consequences of poorly performed intubation attempts, such as airway injury, prolonged hypoxia and other hemodynamic disturbances, are potentially serious (Maharaj 2006). Neonatal Resuscitation Program (NRP) guidelines recommend that an intubation attempt should not be longer than 30 seconds (NRP 2011). In addition, the intubator may need to modify the technique in real time during the attempt under the guidance of the supervisor to achieve the optimal view of the glottis for intubation. Adverse events during endotracheal intubation may be reduced by a technique that is not dependent upon achieving the 'line of sight' required by direct laryngoscopy.

A videolaryngoscope collects electronically processed images from a camera attached at its tip. Images of the airway are visualized on a monitor, which results in improved glottic visualization compared with direct laryngoscopy. Videolaryngoscopy-assisted intubation removes the need for direct line of sight, and this is especially helpful for trainees learning intubation skills in a clinical setting. There is less cervical manipulation and spontaneous ventilation can be preserved during attempts. Videolaryngoscopy may also prove more effective in training scenarios, and may allow trainees to rapidly acquire and maintain their competency of this vital procedural skill.

Why it is important to do this review

Establishment of a secure airway is a critical part of neonatal resuscitation. Videolaryngoscopy is a new technique that has the potential to facilitate successful intubation and decrease adverse consequences of failure or delay of airway stabilization. The costs of videolaryngoscopes (ranging upwards from a few thousand US dollars), personnel training and orientation, equipment storage and maintenance have to be balanced with the benefits achieved. The effects of videolaryngoscopy on improving neonatal outcomes have not been reviewed thus far.

Objectives

Primary objective

To determine the efficacy and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required and increasing the success rate for endotracheal intubation in neonates.

Secondary objectives

To determine the effectiveness of videolaryngoscopy in decreasing the adverse effects:

  • non-airway related: hypoxia, bradycardia and hypotension, due to delay in successful establishment of an airway in neonates;
  • airway-related: airway injury, including palatal, laryngeal or pharyngeal injury.

To analyze subgroups based on birth weight, experience of personnel, presence of congenital airway malformations, type of videolaryngoscopy equipment and setting of intubation if data were available.

Methods

Criteria for considering studies for this review

Types of studies

Randomized, quasi-randomized or cluster-randomized controlled trials.

Types of participants

Neonates (0-28 days of age) who required intubation in the delivery room, operating room or NICU.

Types of interventions

Videolaryngoscopy with any device used for neonatal endotracheal intubation compared with direct laryngoscopy. Videolaryngoscopes that are available for neonatal use including GlideScope, STORZ (C-MAC) and Truview videolaryngoscope.

Types of outcome measures

Primary outcomes
  • Time required for successful intubation defined as total time in seconds from the first insertion of the laryngoscope blade into the mouth until final confirmation of ETT placement by any or a combination of the following: clinical exam (auscultation, visible vapor in the ETT, adequate chest rise and increase in saturation of peripheral oxygen (SpO2)), by end-tidal carbon dioxide (ET-CO2) estimation or by chest radiograph (Choong 2010; Feltman 2011).
  • Number of intubation attempts: insertion and removal of the laryngoscope blade was defined as an attempt irrespective of the success of the intubation (Feltman 2011).
  • Success rate at first attempt.
Secondary outcomes
  • Non-airway related adverse effects:
    • first mean blood pressure in mm Hg (as measured by a cuff or an arterial line) taken after tracheal intubation;
    • lowest recorded O2 saturation (%) from the start of tracheal intubation to normalization of saturation (O2 saturation greater than 95%);
    • time to attain normal saturation in seconds, from the start of tracheal intubation;
    • time to attain normal heart rate in seconds, from the start of tracheal intubation;
    • duration of bradycardia (heart rate less than 100 beats per minute) during and after tracheal intubation;
    • duration of hypoxia (O2 saturation less than 80%) during and after tracheal intubation.
  • Airway-related adverse effects: airway trauma to oral, pharyngeal and laryngeal structures, including lacerations and perforations, assessed by visual or laryngoscopic exam.

Search methods for identification of studies

We used the search strategy of the Cochrane Neonatal Review Group (neonatal.cochrane.org/ External Web Site Policy).

Electronic searches

We searched the following databases for relevant trials.

  • The Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 5).
  • Electronic journal reference databases: MEDLINE (1980 to May 2013) and PREMEDLINE, EMBASE (1980 to May 2013), CINAHL (1982 to May 2013).
  • Biological abstracts in the database BIOSIS and conference abstracts from 'Proceedings First' (from 1992 to 2011).

The following is the MEDLINE and PREMEDLINE search strategy. We adapted this to suit CENTRAL, EMBASE and CINAHL.

  1. explode 'intubation' [all subheadings in MIME, MJME]
  2. laryngoscopy
  3. 'direct laryngoscopy'
  4. videolaryngoscopy
  5. Glidecope
  6. 'McGrath airwayscope'
  7. 'Pentax airwayscope'
  8. 'Truview' optical laryngoscope
  9. 'C-MAC video laryngoscope'
  10. 'Airtraq video laryngoscope'
  11. 'LMA CTrach' video laryngoscope
  12. #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11
  13. explode 'infant - newborn' [all subheadings in MIME, MJME]
  14. Neonat*
  15. Newborn*
  16. #13 or #14 or #15
  17. #12 and #16

We applied no language restrictions.

Searching other resources

We also searched:

  • abstracts of conferences: proceedings of Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research and European Society for Paediatric Research), Pediatric Research (1990 to May 2013) and Abstracts online (2000 to 2011).
  • www.clinicaltrials.gov and www.controlled-trials.com External Web Site Policy for ongoing trials (May 2013).
  • reference lists of identified clinical trials and in the review authors' personal files (May 2013).

We contacted authors in this field for possible unpublished studies.

Data collection and analysis

We used the standardized method of the Cochrane Neonatal Review Group for conducting a systematic review (neonatal.cochrane.org/ External Web Site Policy).

Selection of studies

Two review authors (KL and MP) independently assessed the titles and the abstracts of studies identified by the search strategy for eligibility for inclusion in this review. If this could not done reliably by title and abstract, we obtained the full-text version for assessment. We resolved any differences by mutual discussion. We planned to obtain the full-text version of all available studies for quality assessment; however, we found no studies.

Data extraction and management

We designed forms for trial inclusion or exclusion, data extraction and for requesting additional published information from authors of the original reports. The review authors planned to perform data extraction independently using specifically designed paper forms for identified eligible trials. We planned to compare the extracted data for differences, which we then resolved by discussion.

Assessment of risk of bias in included studies

We found no studies meeting our inclusion criteria in this review. For future updates of the review, two review authors will independently assess the risk of bias for each study using the criteria outlined by the Cochrane Neonatal Review Group to assess the methodologic quality of the eligible studies.

Sequence generation

Was the allocation sequence adequately generated? For each included study, we planned to describe the method used to generate the allocation sequence. We planned to assess the methods as:

  • low risk (any truly random process, e.g. random number table; computer random number generator);
  • high risk (any non-random process, e.g. odd or even date of birth; hospital or clinic record number);
  • unclear risk.
Allocation concealment

Was allocation adequately concealed? For each included study, we planned to describe the method used to conceal the allocation sequence and determine whether intervention allocation could have been foreseen in advance of or during recruitment, or changed after assignment. We planned to assess the methods as:

  • low risk (e.g. telephone or central randomization; consecutively numbered sealed opaque envelopes);
  • high risk (open random allocation; e.g. unsealed or non-opaque envelopes; alternation; date of birth);
  • unclear risk.
Blinding of participants, personnel and outcome assessors

Was knowledge of the allocated intervention adequately prevented during the study? At study entry? At the time of outcome assessment? 

For each included study, we planned to categorize the methods used to blind study participants and personnel from knowledge of which intervention a participant received. Blinding would have been assessed separately for different outcomes or classes of outcomes. We planned to categorize the methods as:  

  • low risk, high risk or unclear risk for participants;
  • low risk, high risk or unclear risk for personnel;
  • low risk, high risk or unclear risk for outcome assessors.
Incomplete outcome data

Were incomplete outcome data adequately addressed? For each included study and for each outcome, we planned to describe the completeness of data including attrition and exclusions from the analysis. We planned to state whether attrition and exclusions were reported, the numbers included in the analysis at each stage (compared with the total number of randomized participants), reasons for attrition or exclusion where reported and whether missing data were balanced across groups or were related to outcomes. We planned to assess the methods as:

  • low risk;
  • high risk;
  • unclear risk.
Selective outcome reporting

Were reports of the study free of suggestion of selective outcome reporting? For each included study, we planned to describe how we examined the possibility of selective outcome reporting bias and what we found.

We planned to assess the methods as:

  • low risk (where it is clear that all of the study's prespecified outcomes and all expected outcomes of interest to the review have been reported);
  • high risk (where not all the study's prespecified outcomes were reported; one or more reported primary outcomes were not prespecified; outcomes of interest were reported incompletely and so could not be used; study did not include results of a key outcome that would have been expected to have been reported);
  • unclear risk.
Other sources of bias

Was the study apparently free of other problems that could put it at a high risk of bias? For each included study, we planned to describe any important concerns regarding other possible sources of bias. We planned to assess whether each study was free of other problems that could put it at risk of bias:

  • low risk;
  • high risk;
  • unclear risk.

Measures of treatment effect

We planned to report RR and risk difference (RD) for dichotomous outcomes and MDs for continuous outcomes and the 95% CIs when eligible trials are identified. We planned to calculate the number needed to treat for an additional beneficial outcome (NNTB) or additional harmful outcome (NNTH) if there is a statistically significant reduction in RD with respective 95% CIs.

Unit of analysis issues

The unit of analysis was the person attempting the intubation (intubator).

Dealing with missing data

We planned to contact the authors of published studies if clarifications were required, or to provide additional information. In the case of missing data, we would have described the number of participants with missing data in the Results section and the Characteristics of included studies table. We planned to present the results for the available participants only. We would have discussed the implications of the missing data in the discussion of the review.

Assessment of heterogeneity

We planned to estimate the treatment effects of individual trials and examine heterogeneity between trials by inspecting the forest plots and quantifying the impact of heterogeneity using the I2 statistic. We would have graded the degree of heterogeneity as low (25% to 50%), moderate (51% to 75%) or high (greater than 75%). If we detected statistical heterogeneity, we planned to explore the possible causes (e.g. differences in study quality, participants, intervention regimens or outcome assessments) using post hoc subgroup analyses. We planned to use a fixed-effect model for meta-analysis.

Assessment of reporting biases

We planned to obtain study protocols of all included studies and compare outcomes reported in the protocols to those reported in the included studies. We planned to investigate reporting and publication bias by examining the degree of asymmetry of a funnel plot. Where we suspect reporting bias, we would have attempted to contact study authors asking them to provide missing outcome data. Where this is not possible, and the missing data are thought to introduce serious bias, we planned to explore the impact of including such studies in the overall assessment of results by sensitivity analyses.

Data synthesis

We planned to use Review Manager 5 software for statistical analysis and intend to use a fixed-effect model for meta-analysis when eligible trials are identified (RevMan 2011). We would have performed statistical analyses according to the recommendations of the Cochrane Neonatal Review Group.

Subgroup analysis and investigation of heterogeneity

We will base subgroups on the following in future updates of the review when data are available.

Birth weight groups:
  • 1500 g or less;
  • greater than 1500 g.
Personnel groups:
  • personnel with less than one year of tracheal intubation experience;
  • personnel with one to three years of tracheal intubation experience;
  • Personnel with greater than three years of tracheal intubation experience.
Presence of airway malformations:
  • airway malformations;
  • no airway malformations.
Type of neonatal videolaryngoscopy equipment:
  • integrated channel laryngoscope (CTrach, Pentax AWS, Airtaq);
  • video stylets (Bonfils);
  • rigid blade laryngoscopes (C-MAC, GlideScope, McGrath, Truview);
  • direct laryngoscope.
Setting:
  • emergent;
  • non-emergent.

Sensitivity analysis

We planned to explore methodologic heterogeneity of eligible trials using sensitivity analyses.

Results

Description of studies

Results of the search

Our search strategy performed in May 2013 yielded 7057 references, which two review authors (MP and KL) independently reviewed. Most excluded randomized trials had performed the trials on mannequins in a simulated environment and not on people. Clinical trials randomizing people to videolaryngoscopy or conventional direct laryngoscopy were mostly in adults and older children. We found two potential studies, one study that we excluded due to non-neonatal population (Fiadjoe 2012), and one study where we did not get a response from the author regarding the age of the participants (Singh 2009). We also identified three ongoing trials (Karsli 2012; Soerensen 2010; Yomul 2012).

Included studies

We identified no trials that matched our inclusion criteria.

Excluded studies

We excluded two studies (Fiadjoe 2012; Vlatten 2009; see Characteristics of excluded studies table).

Vlatten and co-investigators randomized 56 children aged four years or less to direct laryngoscopy or videolaryngoscopy using STORZ DCI videolaryngoscope. Outcomes reported were time to best view, time to intubate and percentage of glottis opening seen. The median age was 25 months (range 7 to 58) in the direct laryngoscopy group and 32 months (range 6 to 57) in the videolaryngoscopy group. No neonates were included in the study and hence we excluded the study.

Fiadjoe and co-investigators randomized 60 infants, aged less than one year, who underwent elective surgery to GlideScope Cobalt videolaryngoscope or conventional direct laryngoscopy (Miller 1 blade) in Philadelphia, USA. The mean age (standard deviation (SD)) was 5.9 months (3.4) in the GlideScope group and 5.1 months (3.3) in the direct laryngoscopy group. Male to female ratios were not different in the two groups. Outcomes reported were intubation time, time to best view, percentage of glottic opening score and intubation success. The youngest participant was aged one month and 12 days old and hence we excluded this study.

Studies awaiting classification

We found one study that randomized 60 neonates and infants who underwent surgery in New Delhi, India to Truview infant EVO2 or direct laryngoscopy with the Miller blade (Singh 2009; see Characteristics of studies awaiting classification table). The mean age (SD) of the participants was 0.69 months (1.20) in the Truview group and 0.74 months (1.21) in the direct laryngoscopy group. Male to female ratios in both groups were similar. All infants weighed between 1 kg and 10 kg. Exclusion criteria included the presence of raised intracranial pressure, high risk for pulmonary aspiration of gastric contents such as gastric outlet obstruction and bowel stasis, coagulopathy and presence of any pathology of head and neck. Outcomes reported were; number of attempts required for intubation, time to intubation, percentage of glottic opening score, hemoglobin oxygen saturation and soft tissue injury related to intubation. We have requested data for neonates from the investigators.

Ongoing studies

We identified three ongoing trials (Karsli 2012; Soerensen 2010; Yomul 2012; see Characteristics of ongoing studies table).

Risk of bias in included studies

We identified no eligible studies for inclusion.

Effects of interventions

We identified no eligible studies for inclusion.

Discussion

Not applicable since we identified no eligible studies for inclusion.

Summary of main results

We identified no eligible randomized controlled trials for inclusion that compared videolaryngoscopy with conventional direct laryngoscopy for endotracheal intubation in newborns. We could not obtain neonatal data from investigators of one study that had the potential for inclusion (Singh 2009). We also identified three ongoing trials (Karsli 2012; Soerensen 2010; Yomul 2012).

Overall completeness and applicability of evidence

We identified no eligible studies for inclusion.

Quality of the evidence

We identified no eligible studies for inclusion.

Potential biases in the review process

We used the standard methods of the Cochrane Neonatal Review Group for conducting this systematic review. Our inclusive search strategy would have included all relevant studies. We minimized any potential biases.

Agreements and disagreements with other studies or reviews

Not applicable.

Authors' conclusions

Implications for practice

We did not find any studies that met our inclusion criteria and hence there is no evidence to recommend or refute the use of videolaryngoscopy in neonates.

Implications for research

Well-designed randomized controlled trials are necessary to evaluate the efficacy and safety of videolaryngoscopy in neonatal intubation. Such trials should also evaluate cost-effectiveness and address training of caregivers. Clinically relevant outcomes, such as drop in oxygen saturation, prolonged bradycardia or hypoxia, should be reported. Videolaryngoscopy should be evaluated in settings where intubation is commonly performed including the delivery room and the neonatal intensive care unit. Comparison of videolaryngoscopy and direct laryngoscopy in neonates with a difficult airway also needs further evaluation.

Acknowledgements

We thank Yolanda Brousseau at the Cochrane Neonatal Review Group for help with the search in EMBASE.

Contributions of authors

KL reviewed the literature and wrote the review.

MP assisted in the review of literature and wrote the review.

JA, TS and CF critiqued and helped to incorporate peer review comments in the review.

Declarations of interest

None of the review authors has declared any conflict of interest, financial or otherwise.

Differences between protocol and review

None noted.

Characteristics of studies

Characteristics of included studies

None noted.

Characteristics of excluded studies

Fiadjoe 2012

Reason for exclusion

No neonates included in the study

Vlatten 2009

Reason for exclusion

Pediatric participants aged < 4 years but no neonates

Characteristics of studies awaiting classification

Singh 2009

Methods

Prospective randomized study to compare the Truview infant EVO2 laryngoscope with the Miller straight blade laryngoscope in order to determine whether the Truview EVO2 laryngoscope provided an improved laryngeal view at laryngoscopy and also to assess the time taken for intubation with the 2 devices

Participants

60 neonates and infants of either sex undergoing surgery under general anesthesia weighing 1-10 kg.

Exclusion criteria: presence of raised intracranial pressure, high risk for pulmonary aspiration of gastric contents such as gastric outlet obstruction and bowel stasis, coagulopathy and presence of any pathology of head and neck

Interventions

Endotracheal intubation using a Truview blade (Group I) vs. a Miller blade number 0 (Group II)

Outcomes

Number of attempts required for intubation, time to intubation, percentage of glottic opening score, hemoglobin oxygen saturation and soft tissue injury related to intubation

Notes

Awaiting data related to neonates from the investigators

Characteristics of ongoing studies

Karsli 2012

Study name

Infant GlideScope Learning Curve

Methods

Prospective interventional efficacy study evaluating the learning curve associated with the use of videolaryngoscopy compared with conventional direct laryngoscopy in infants intubated by anesthesiology residents

Participants

Infants < 10 kg, aged ≤ 18 months undergoing general anesthesia and requiring tracheal intubation

Interventions

Tracheal intubation using the GlideScope videolaryngoscope vs. direct laryngoscopy

Outcomes

Primary outcome: time to optimum visualization of the vocal cords

Secondary outcome: time to tracheal intubation

Starting date

July 2011

Contact information 
Notes 

Soerensen 2010

Study name

Intubation with STORZ Videolaryngoscope versus Airtaq in an Infant Population

Methods

Prospective randomized safety/efficacy study comparing the STORZ videolaryngoscope with the Airtaq videolaryngoscope for endotracheal intubation in children

Participants

Elective surgical patients American Society of Anesthesiologists (ASA) class 1-2, aged < 2 years, with indication for intubation

Interventions

All participants will be evaluated with a Macintosh blade laryngoscope, with an Airtaq or a STORZ videolaryngoscope and finally intubated with the device that the participant was randomized to be intubated

Outcomes

Primary outcome: success rate

Secondary outcomes: time to Cormack evaluation, time to intubation, number of intubation attempts, quality of laryngeal overview before intubation, prevalence of post-intubation stridor and intubation conditions

Starting date

March 2010

Contact information 
Notes 

Yomul 2012

Study name

Study to Compare Video Miller Device to Direct Laryngoscopy

Methods

Randomized prospective study comparing the video Miller device with direct laryngoscopy for tracheal intubation in children aged < 3 years undergoing general anesthesia

Participants

Patients aged < 3 years American Society of Anesthesiologists (ASA) I-II undergoing general anesthesia

Interventions

Intubation using the Video-Miller laryngoscope vs. direct laryngoscope

Outcomes

Primary outcome: intubation time

Secondary outcome: glottic visualization and percentage of glottic opening score

Starting date

June 2011

Contact information 
Notes 

References to studies

Included studies

None.

Excluded studies

Fiadjoe 2012

Published and unpublished data [Other: ]

Fiadjoe JE, Gurnaney H, Dalesio N, Sussman E, Zhao H, Zang X, et al. A prospective randomized equivalence trial of the GlideScope Cobalt video laryngoscope to traditional direct laryngoscopy in neonates and infants. Anesthesiology 2012;116(3):622-8.

Vlatten 2009

Vlatten A, Aucoin S, Litz S, Macmanus B, Soder C. A comparison of the STORZ video laryngoscope and standard direct laryngoscopy for intubation in the Pediatric airway - a randomized clinical trial. Paediatric Anaesthesia 2009;19(11):1102-7.

Studies awaiting classification

Singh 2009

Singh R, Singh P, Vajifdar H. A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants. Paediatric Anaesthesia 2009;19(4):338-42.

Ongoing studies

Karsli 2012

Unpublished data only [ClinicalTrials.gov: NCT01793727]

Soerensen 2010

Unpublished data only [ClinicalTrials.gov: NCT01090726]

Yomul 2012

Unpublished data only [ClinicalTrials.gov: NCT01371032]

Other references

Additional references

Asai 2008

Asai T, Enomoto Y, Shimizu K, Shingu K, Okuda Y. The Pentax-AWS video-laryngoscope: the first experience in one hundred patients. Anesthesia and Analgesia 2008;106(1):257-9.

Aziz 2012

Aziz MF, Dillman D, Fu R, Brambrink AM. Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Anesthesiology 2012;116(3):629-36.

Choong 2010

Choong K, AlFaleh K, Doucette J, Gray S, Rich B, Verhey L, et al. Remifentanil for endotracheal intubation in neonates: a randomised controlled trial. Archives of Disease in Childhood. Fetal and Neonatal Edition 2010;95(2):F80-4.

Falck 2003

Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics 2003;112(6 Pt 1):1242-7.

Feltman 2011

Feltman DM, Weiss MG, Nicoski P, Sinacore J. Rocuronium for nonemergent intubation of term and preterm infants. Journal of Perinatology 2011;31(1):38-43.

Griesdale 2012

Griesdale DE, Liu D, McKinney J, Choi PT. Glidescope(R) video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Canadian Journal of Anaesthesia 2012;59(1):41-52.

Healy 2012

Healy DW, Maties O, Hovord D, Kheterpal S. A systematic review of the role of videolaryngoscopy in successful orotracheal intubation. BMC Anesthesiology 2012;12:32.

Hirabayashi 2007

Hirabayashi Y, Seo N. Tracheal intubation by non-anaesthetist physicians using the Airway Scope. Emergency Medicine Journal 2007;24(8):572-3.

Hirabayashi 2008

Hirabayashi Y, Seo N. Airway Scope: early clinical experience in 405 patients. Journal of Anesthesia 2008;22(1):81-5.

Kim 2008

Kim JT, Na HS, Bae JY, Kim DW, Kim HS, Kim CS, et al. GlideScope video laryngoscope: a randomized clinical trial in 203 paediatric patients. British Journal of Anaesthesia 2008;101(4):531-4.

Lim 2005

Lim TJ, Lim Y, Liu EH. Evaluation of ease of intubation with the GlideScope or Macintosh laryngoscope by anaesthetists in simulated easy and difficult laryngoscopy. Anaesthesia 2005;60(2):180-3.

Maharaj 2006

Maharaj CH, Costello JF, Higgins BD, Harte BH, Laffey JG. Learning and performance of tracheal intubation by novice personnel: a comparison of the Airtraq and Macintosh laryngoscope. Anaesthesia 2006;61(7):671-7.

NRP 2011

Kattwinkel J. Textbook of Neonatal Resuscitation. 6th edition. Elk Grove Village: American Academy of Pediatrics and American Heart Association, 2011.

Pott 2008

Pott LM, Murray WB. Review of video laryngoscopy and rigid fiberoptic laryngoscopy. Current Opinion in Anaesthesiology 2008;21:750-8.

RevMan 2011

Review Manager (RevMan) [Computer program]. Version 5.1. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2011.

Roberts 2006

Roberts KD, Leone TA, Edwards WH, Rich WD, Finer NN. Premedication for nonemergent neonatal intubations: a randomized, controlled trial comparing atropine and fentanyl to atropine, fentanyl, and mivacurium. Pediatrics 2006;118(4):1583-91.

Shippey 2007

Shippey B, Ray D, McKeown D. Case series: the McGrath videolaryngoscope-an initial clinical evaluation. Canadian Journal of Anaesthesia 2007;54(4):307-13.

Shippey 2008

Shippey B, Ray D, McKeown D. Use of the McGrath videolaryngoscope in the management of difficult and failed tracheal intubation. British Journal of Anaesthesia 2008;100(1):116-9.

Thong 2009

Thong SY, Lim Y. Video and optic laryngoscopy assisted tracheal intubation - the new era. Anaesthesia and Intensive Care 2009;37(2):219-33.

Vanderhal 2009

Vanderhal AL, Berci G, Simmons CF Jr, Hagiike M. A videolaryngoscopy technique for the intubation of the newborn: preliminary report. Pediatrics 2009;124(2):e339-46.

Weiss 2001

Weiss M, Schwarz U, Dillier CM, Gerber AC. Teaching and supervising tracheal intubation in paediatric patients using videolaryngoscopy. Pediatric Anesthesia 2001;11(3):343-8.

Xue 2006

Xue F, Zhang G, Liu J, Li X, Sun H, Wang X, et al. A clinical assessment of the GlideScope videolaryngoscope in nasotracheal intubation with general anesthesia. Journal of Clinical Anesthesia 2006;18(8):611-5.

Classification pending references

None noted.

Data and analyses

None included.

Figures

None included.

Sources of support

Internal sources

  • None, Other

External sources

  • Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA
  • Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN275201100016C.

    This review is published as a Cochrane review in The Cochrane Library, Issue 2, 2015 (see http://www.thecochranelibrary.com External Web Site Policy for information).  Cochrane reviews are regularly updated as new evidence emerges and in response to feedback.  The Cochrane Library should be consulted for the most recent version of the review.