John: Hello, I'm John Hilton, editor in the Cochrane Editorial and Methods department. As you can imagine, placing a breathing tube into a newborn baby is a particularly challenging task, and research has been done into different ways to do this. In June 2018, Mohan Pammi and Krithika Lingappan from Baylor College of Medicine in Houston in the USA updated the Cochrane review on comparing videolaryngoscopy to the traditional direct laryngoscopy approach and they describe the latest findings in this podcast, starting with Mohan.

Mohan: About one in a hundred newborn babies may need intubation to insert a breathing tube because of difficulty breathing. This is a life-saving procedure that needs to be performed in the delivery room and neonatal intensive care units. It can be technically challenging and requires practice, and successful intubation needs adequate visualization of the airway and related structures. The unique neonatal airway anatomy decreases adequate visibility of the airway making it difficult to train junior colleagues in the procedure. Poor visualization can lead to prolonged or repeated intubation attempts, which can cause airway injury or hypoxia in the baby. Videolaryngoscopy can make airway visualization much easier in babies.
When training junior colleagues, supervisors of intubation training rely mainly on feedback from the trainee rather than visual confirmation. So, the instructors often cannot recognize the trainee's problem and may need to take over and do the tracheal intubation themselves. Videolaryngoscopy can help both the trainer and the trainee in identifying anatomical structures in the airway and enhance the success of intubation. We set out, therefore, to determine efficacy and safety of videolaryngoscopy compared to the traditional direct laryngoscopy, without video. In particular, we were interested in the time and attempts required for successful intubation.

Krithika: In our updated review, we included three eligible randomized trials performed in Canada, Australia and the United States. The participants of these studies were trainees, not experienced physicians, which highlights the use of videolaryngoscopy mainly as a teaching tool, especially in light of the positive findings. Synthesis of data from the studies shows that videolaryngoscopy increases the intubation success at the first attempt but does not decrease the time to intubation, the number of attempts or side effects due to placement of the breathing tube.
This evidence can be set against of background of increasing interest in videolaryngoscopy as a clinical teaching tool, in the wake of duty hour restrictions and decreasing opportunities for trainees to gain competence in the procedure. The number of intubation opportunities is further decreased by the presence of additional advanced providers, such as respiratory therapists and nurse practitioners, and growing use of non-invasive respiratory support in preterm babies. However, even though we have shown that videolaryngoscopy increased success of intubation on the first attempt by trainees, the finding cannot be extended to intubation by expert providers. In addition, the cost may be prohibitive, and the availability of these devices may be limited in low-resource settings. 

Mohan: In summary, there is moderate to very low-quality evidence that the use of videolaryngoscopy by trainees increases success at first attempt of intubation but does not decrease time to intubation. We hope that our findings will encourage more research with appropriately designed randomized trials to confirm efficacy, safety and cost-effectiveness of videolaryngoscopy for endotracheal intubation in neonates. These trials should include both trainees and those proficient in direct laryngoscopy.

John: To read more about the current evidence and to watch for future updates of the review as any such additional evidence becomes available, go online to Cochrane Library dot com and search 'videolaryngoscopy and neonates'.