Key Messages
Videolaryngoscopy may increase the success of placing a breathing tube on the first attempt, and may result in slightly fewer tries by a care provider to place the breathing tube in sick newborn babies, but it does not reduce the amount of time it takes to place the breathing tube.
Videolaryngoscopy likely results in slightly less injury to the newborn baby's airway while the breathing tube is being placed.
We need better studies to understand the role of videolaryngoscopy in different practice areas and with different care providers doing the placement.
What is the problem?
One in 100 newborn babies may need a breathing tube placed in their mouth or nose to keep them alive when they have difficulty breathing. Placing a breathing tube using direct laryngoscopy (without video assistance) may be challenging in newborns because their mouths and airways are small, and not all care providers are experienced.
What is videolaryngoscopy?
Seeing the airway by a video while placing the breathing tube is called videolaryngoscopy. This may make it easier and safer to place the breathing tube. This also may help trainees when they are learning this life-saving skill.
What did we want to find out?
We wanted to find out if using videolaryngoscopy increased the success and safety of the placement of a breathing tube compared to the direct laryngoscopy technique, in babies who were 0 to 28 days old.
What did we do?
We searched for studies that were trying to find out whether video devices were better than the standard approach without video assistance (direct laryngoscopy) for placing breathing tubes in babies. The studies could measure time, the number of attempts, the success rate of the first attempt to place the breathing tube, or side effects.
We compared and summarized the results of the studies, and rated our confidence in the evidence, based on factors such as study methods and sizes.
What did we find?
We found eight eligible studies, which included 759 intubation attempts in newborn babies. They reported time, the number of attempts, the success rate of the first attempt to place the breathing tube, and side effects. In summary:
Videolaryngoscopy may increase the success of placing a breathing tube on the first attempt, and may result in slightly fewer tries by a care provider to place the breathing tube in sick newborn babies, but does not reduce the amount of time it takes to place the breathing tube.
Videolaryngoscopy may have little or no effect on how many babies have episodes of low oxygen or low heart rate (or both) while the breathing tube is being placed, but the evidence is very uncertain. Videolaryngoscopy may result in little or no difference in the lowest levels of oxygen while the breathing tube is being placed.
Videolaryngoscopy likely results in slightly less injury to the newborn baby’s airway while the breathing tube is being placed.
There were no data available on other adverse effects while the breathing tube is being placed.
What are the limitations of the evidence?
We found that the included studies were small, we were unable to assess the risk of bias in some, and the study results varied. The care providers who placed the breathing tube knew which device was being used. This decreases our confidence in the results of the review, and the results of further research could differ from the results of this review.
Funding and equipment support was provided in some of the included studies. In some cases, funding sources and declarations of interest were not stated.
How up to date is this evidence?
The evidence is up to date to November 2022.
Videolaryngoscopy may increase the success of intubation on the first attempt and may result in fewer intubation attempts, but may not reduce the time required for successful intubation (low-certainty evidence). Videolaryngoscopy likely results in a reduced incidence of airway-related adverse effects (moderate-certainty evidence).
These results suggest that videolaryngoscopy may be more effective and potentially reduce harm when compared to direct laryngoscopy for endotracheal intubation in neonates.
Well-designed, adequately powered RCTS are necessary to confirm the efficacy and safety of videolaryngoscopy in neonatal intubation.
Establishment of a secure airway is a critical part of neonatal resuscitation in the delivery room and the neonatal intensive care unit. Videolaryngoscopy has the potential to facilitate successful endotracheal intubation, and decrease adverse consequences of a delay in airway stabilization. Videolaryngoscopy may enhance visualization of the glottis and intubation success in neonates. This is an update of a review first published in 2015, and updated in 2018.
To determine the effectiveness and safety of videolaryngoscopy compared to direct laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate on first intubation attempt in neonates (0 to 28 days of age).
In November 2022, we updated the search for trials evaluating videolaryngoscopy for neonatal endotracheal intubation in CENTRAL, MEDLINE, Embase, CINAHL, and BIOSIS. We also searched abstracts of the Pediatric Academic Societies, clinical trials registries (www.clinicaltrials.gov; www.controlled-trials.com), and reference lists of relevant studies.
Randomized controlled trials (RCTs), quasi-RCTs, cluster-RCTs, or cross-over trials, in neonates (0 to 28 days of age), evaluating videolaryngoscopy with any device used for endotracheal intubation compared with direct laryngoscopy.
Three review authors performed data collection and analysis, as recommended by Cochrane Neonatal. Two review authors independently assessed studies identified by the search strategy for inclusion.
We used the GRADE approach to assess the certainty of the evidence.
The updated search yielded 7786 references, from which we identified five additional RCTs for inclusion, seven ongoing trials, and five studies awaiting classification. Three studies were included in the previous version of the review. For this update, we included eight studies, which provided data on 759 intubation attempts in neonates. We included neonates of either sex, who were undergoing endotracheal intubation in international hospitals. Different videolaryngoscopy devices (including C-MAC, Airtraq, and Glidescope) were used in the studies.
For the primary outcomes; videolaryngoscopy may not reduce the time required for successful intubation when compared with direct laryngoscopy (mean difference [MD] 0.74, 95% confidence interval [CI] -0.19 to 1.67; 5 studies; 505 intubations; low-certainty evidence). Videolaryngoscopy may result in fewer intubation attempts (MD -0.08, 95% CI -0.15 to 0.00; 6 studies; 659 intubations; low-certainty evidence). Videolaryngoscopy may increase the success of intubation at the first attempt (risk ratio [RR] 1.24, 95% CI 1.13 to 1.37; risk difference [RD] 0.14, 95% CI 0.08 to 0.20; number needed to treat for an additional beneficial outcome [NNTB] 7, 95% CI 5 to 13; 8 studies; 759 intubation attempts; low-certainty evidence).
For the secondary outcomes; the evidence is very uncertain about the effect of videolaryngoscopy on desaturation or bradycardia episodes, or both, during intubation (RR 0.94, 95% CI 0.38 to 2.30; 3 studies; 343 intubations; very-low certainty evidence). Videolaryngoscopy may result in little to no difference in the lowest oxygen saturations during intubation compared with direct laryngoscopy (MD -0.76, 95% CI -5.74 to 4.23; 2 studies; 359 intubations; low-certainty evidence). Videolaryngoscopy likely results in a slight reduction in the incidence of airway trauma during intubation attempts compared with direct laryngoscopy (RR 0.21, 95% CI 0.05 to 0.79; RD -0.04, 95% CI -0.07 to -0.01; NNTB 25, 95% CI 14 to 100; 5 studies; 467 intubations; moderate-certainty evidence).
There were no data available on other adverse effects of videolaryngoscopy. We found a high risk of bias in areas of allocation concealment and performance bias in the included studies.