Is Videolaryngoscopy the New Gold Standard for Intubation Following the COVID-19 Crisis?

Patients admitted to Intensive Care Units (ICU) often require respiratory support. Orotracheal intubation is one of the most frequent procedures performed in ICU (Lascarrou et al. 2017; Roux et al. 2014; Martin et al. 2020).When performed in critically ill patients, intubation is a challenging issue as it may be associated with life-threatening complications in up to one third of cases (Jaber et al. 2006; De Jong et al. 2013b). Severe hypoxaemia occurring during intubation procedure can result in cardiac arrest (Mort 2004; De Jong et al. 2018), cerebral anoxia, and death (Cook et al. 2010). Difficult intubation is known to be associated with life-threatening complications (De Jong et al. 2013b; De Jong et al. 2014a; Jaber et al. 2006; Jaber et al. 2010; Martin et al. 2011; Driver et al. 2018).The failure of first-attempt intubation appears a major factor for developing life-threatening complications related to intubation (De Jong et al. 2020).

In this setting, the place of videolaryngoscopy for intubation procedure in critically ill patients remains debated in the past years (Jaber et al. 2019; Mosier et al. 2020). However, the recent COVID-19 pandemic highlighted the potential usefulness of videolaryngoscopy to reduce intubation provider contamination (El-Boghdadly et al. 2020; Cook et al. 2020; Patwa et al. 2020). Is videolaryngoscopy the new gold standard for intubation during and after the COVID-19 crisis?

What are the Videolaryngoscopes?

Videolaryngoscopes were first proposed to improve airway management through improved glottis visualisation, aiming to reduce incidence of difficult intubation in the operating room. Then, their use was extended to airway management in other settings. These devices contain a miniaturised camera aimed at the tip of the blade to indirectly visualise the glottis.

Videolaryngoscopes differ in design, blade type and technical configuration. Three main categories of videolaryngoscopes exist according to the type of blade. First, the Macintosh blade-shaped optical laryngoscopes have Macintosh blades combined with video technology. The glottis can be seen either directly or via a video screen. Second, the anatomically shaped blades without a tube guide have anatomically shaped, giving a view of the glottis without the need to flex or extend the neck, providing only an indirect view of the glottis, with the need to use a preshaped stylet into the tracheal tube. Third, the anatomically shaped blade with a tube guide do not necessitate a preshaped stylet.

Despite the better visualisation of the glottis, the main challenge when using videolaryngoscopes remains to insert the tube into the trachea. In other terms, achieving a 100% percentage of glottis opening (POGO) view (corresponding to a Cormack-Lehane grade 1 in direct laryngoscopy) during videolaryngoscopy does not guarantee successful intubation, as the tube has to pass a sharp angle to enter the larynx. Table 1 presents ten tips to improve first-attempt intubation success using videolaryngoscopes.

What are the Data in Literature?

In the ICU setting in the 2010’s, it has been suggested that videolaryngoscopes could help to reduce difficult intubation rate (Kory et al. 2013; Lakticova et al. 2013). In a before-after study reporting a quality improvement process using a videolaryngoscope in an airway management algorithm (De Jong et al. 2013a), the systematic use of a combo videolaryngoscope for intubation significantly reduced the incidence of difficult intubation and/or difficult laryngoscopy (De Jong et al. 2013a). In the multivariate analysis, the "standard laryngoscopy" group was an independent risk factor for difficult intubation and/or difficult laryngoscopy. In addition, in the subgroup of patients with difficult intubation predicted by the MACOCHA score (De Jong et al. 2013b), the incidence of difficult intubation was much higher in the "standard laryngoscopy" group (47%) than in the "combo videolaryngoscope" group (0%).

These results were confirmed in 2014 by a systematic review and meta-analysis establishing that use of videolaryngoscopes for intubation in ICU could reduce the rate of difficult intubation (De Jong et al. 2014b). Videolaryngoscopy improved difficult intubation, first-attempt success, Cormack 3/4 grades, oesophageal intubation, and did not modify severe hypoxaemia, severe cardiovascular collapse, and airway injury, when compared with direct laryngoscopy. However, in 2016, Lascarrou et al. (2017) showed in a large multicentre randomised controlled trial that videolaryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications.

Several meta-analyses (Arulkumaran et al. 2018; Zhao et al. 2017; Huang et al. 2017) were then published, with conflicting results regarding the superiority of the videolaryngoscopes over direct laryngoscopy for intubation in critically ill patients. The disparities between included trials were however considerable, with high heterogeneity.

A prospective observational study that compares the use of direct laryngoscopy with a conventional Macintosh blade to the C-MAC® videolaryngoscope (Karl-Storz) (Dey et al. 2020), among operators that had performed, at least, 50 intubations in clinical simulation with the videolaryngoscope, was recently performed. In the videolaryngoscope group, there was a higher first-attempt intubation rate than in the conventional Macintosh blade group.