Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (<scp>NEAR</scp>) Study

<jats:title>Abstract</jats:title><jats:sec><jats:title>Objective</jats:title><jats:p>The objective was to compare first‐attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (<jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content>) with unaided video laryngoscopy (<jats:styled-content style="fixed-case">VL</jats:styled-content>) in adult emergency department (<jats:styled-content style="fixed-case">ED</jats:styled-content>) intubations.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>This study was a secondary analysis of a multicenter prospective observational database of <jats:styled-content style="fixed-case">ED</jats:styled-content> intubations from the National Emergency Airway Registry (<jats:styled-content style="fixed-case">NEAR</jats:styled-content>). We compared all <jats:styled-content style="fixed-case">VL</jats:styled-content> procedures to seven exploratory permutations of <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> using multivariable regression models. We further stratified by blade shape into hyperangulated <jats:styled-content style="fixed-case">VL</jats:styled-content> (<jats:styled-content style="fixed-case">HA</jats:styled-content>‐<jats:styled-content style="fixed-case">VL</jats:styled-content>) and standard‐geometry <jats:styled-content style="fixed-case">VL</jats:styled-content> (<jats:styled-content style="fixed-case">SG</jats:styled-content>‐<jats:styled-content style="fixed-case">VL</jats:styled-content>). We report differences in first‐attempt intubation success and peri‐intubation adverse events with cluster‐adjusted odds ratios (<jats:styled-content style="fixed-case">OR</jats:styled-content>s) with 95% confidence intervals (<jats:styled-content style="fixed-case">CI</jats:styled-content>s). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and <jats:styled-content style="fixed-case">OR</jats:styled-content> with 95% <jats:styled-content style="fixed-case">CI</jats:styled-content>.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> or unaided <jats:styled-content style="fixed-case">VL</jats:styled-content> on first attempt. <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> was used first in 3,936 (56.7%, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 46.9 to 66.5) versus unaided <jats:styled-content style="fixed-case">VL</jats:styled-content> in 3,002 (43.3%, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 33.5 to 53.1). Of the <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (<jats:styled-content style="fixed-case">ELM</jats:styled-content>), and 365 (9.3%) used a bougie. Rapid sequence intubation (<jats:styled-content style="fixed-case">RSI</jats:styled-content>) was the most common method used in 5,602 (80.8%, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 77.0 to 84.5) cases. First‐attempt success was significantly higher with all <jats:styled-content style="fixed-case">VL</jats:styled-content> (90.9%, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 88.7 to 93.1) versus all <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> (81.1%, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 78.7 to 83.5) despite the <jats:styled-content style="fixed-case">VL</jats:styled-content> group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry‐recorded difficult airway predictors revealed first‐attempt success was higher with all unaided <jats:styled-content style="fixed-case">VL</jats:styled-content> compared with any <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> (adjusted <jats:styled-content style="fixed-case">OR</jats:styled-content> [<jats:styled-content style="fixed-case">AOR</jats:styled-content>] = 2.8, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 2.4 to 3.3), <jats:styled-content style="fixed-case">DL</jats:styled-content> with bougie (<jats:styled-content style="fixed-case">AOR</jats:styled-content> = 2.7, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 2.1 to 3.5), <jats:styled-content style="fixed-case">DL</jats:styled-content> with <jats:styled-content style="fixed-case">ELM</jats:styled-content> (<jats:styled-content style="fixed-case">AOR</jats:styled-content> = 1.8, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 1.5 to 2.2), <jats:styled-content style="fixed-case">DL</jats:styled-content> with ramped positioning (<jats:styled-content style="fixed-case">AOR</jats:styled-content> = 2.8, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 2.3 to 3.3), or <jats:styled-content style="fixed-case">DL</jats:styled-content> with <jats:styled-content style="fixed-case">ELM</jats:styled-content> plus bougie (<jats:styled-content style="fixed-case">AOR</jats:styled-content> = 2.8, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 2.3 to 3.3). Subgroup analyses of <jats:styled-content style="fixed-case">HA</jats:styled-content>‐<jats:styled-content style="fixed-case">VL</jats:styled-content> and <jats:styled-content style="fixed-case">SG</jats:styled-content>‐<jats:styled-content style="fixed-case">VL</jats:styled-content> compared with any <jats:styled-content style="fixed-case">A</jats:styled-content>‐<jats:styled-content style="fixed-case">DL</jats:styled-content> yielded similar results (<jats:styled-content style="fixed-case">AOR</jats:styled-content> = 3.2, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 2.6 to 3.0; and <jats:styled-content style="fixed-case">AOR</jats:styled-content> = 2.4, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 1.9 to 3.0, respectively). The propensity score–adjusted odds for first‐attempt success with <jats:styled-content style="fixed-case">VL</jats:styled-content> was also 2.8 (95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 2.4 to 3.3). Fewer esophageal intubations were observed in the <jats:styled-content style="fixed-case">VL</jats:styled-content> cohort (0.4% vs. 1.3%, <jats:styled-content style="fixed-case">AOR</jats:styled-content> = 0.2, 95% <jats:styled-content style="fixed-case">CI</jats:styled-content> = 0.1 to 0.5).</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first‐attempt success than does <jats:styled-content style="fixed-case">DL</jats:styled-content> that is augmented by use of a bougie, <jats:styled-content style="fixed-case">ELM</jats:styled-content>, ramping, or combinations thereof.</jats:p></jats:sec>