Direct Versus Video Laryngoscopy for Prehospital Intubation: A Systematic Review and Meta-analysis

The use of video laryngoscopy (VL) for intubation has gained recent popularity. In the prehospital setting, it is unclear if VL increases intubation success rates compared to direct laryngoscopy (DL). We sought to conduct a systematic review and meta-analysis of studies comparing VL to DL in the prehospital setting to determine whether the use of VL increases overall and first-pass endotracheal intubation success rates compared to DL.

A systematic search was performed of the PubMed, Embase, and SCOPUS databases through May 2016 to include studies comparing overall and first-pass success for VL versus DL in patients requiring intubation in the prehospital setting. Data were abstracted by two reviewers. A meta-analysis was performed using a random-effects model.

Of a potential 472 articles, eight eligible studies were included. Considerable heterogeneity (I²  > 90%) precluded reporting an overall pooled estimate across all studies. When stratified by provider type, the pooled estimates for overall intubation success using VL versus DL were a risk ratio (RR) of 0.05 (95% confidence interval [CI] = 0.01-0.18) in studies of physicians and RR = 2.28 (95% CI = 1.00-5.20) in nonphysicians. For first-pass intubation success the pooled RR estimates for using VL versus DL were 0.32 (95% CI = 0.23-0.44) and 1.83 (95% CI = 1.18-2.84) among studies using physicians and nonphysicians, respectively. There was moderate to significant heterogeneity between studies when stratified by provider.

Among physician intubators with significant DL experience, VL does not increase overall or first-pass success rates and may lead to worsening performance. However, among nonphysician intubators with less experience with DL, VL may provide benefit in the prehospital setting.