Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. 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 May 2023, Mohan Pammi and co-reviewers from Baylor College of Medicine, Children's Hospital of Philadelphia and Boston Children's Hospital, updated the Cochrane review on comparing videolaryngoscopy to the traditional direct laryngoscopy approach and Mohan describes the latest findings in this podcast.

Mohan: About one in a hundred newborn babies may need intubation to insert a breathing tube because of difficulty in breathing. This is a life-saving procedure that needs to be performed in the delivery room or in the neonatal intensive care units. It can be technically challenging, requires practice, and successful intubation needs adequate visualization of the airway and related structures. The unique anatomy of the neonatal airway decreases adequate visibility, making it difficult to train junior colleagues in this 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, increasing success of the procedure and decrease adverse effects.
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 find out if videolaryngoscopy enhances success at intubation and is safer compared to the traditional direct laryngoscopy, without video. In particular, we were interested in how long it took for the procedure and number of attempts required for successful intubation.
In our updated review, we included eight eligible randomized trials in neonates, which provided data on 759 intubation attempts. The studies were performed in Australia, Canada, China, Egypt, India, the UK, and the USA. The participants in these studies were not only trainees but also providers who were proficient in neonatal intubation, which highlights the use of videolaryngoscopy not only as a teaching tool but also in assisting clinical care. The synthesis of data from the studies shows that videolaryngoscopy increases intubation success at first attempt, decreases the number of attempts and decreases airway injury but increases time to intubation.
This evidence should be viewed against a 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 including respiratory therapists and nurse practitioners, and growing use of non-invasive respiratory support in preterm babies. However, the cost of procuring and maintaining Videolaryngoscopes may be prohibitive, and the availability of these devices may be limited in low-resource settings.
In summary, moderate to low certainty evidence suggests that the use of videolaryngoscopy by trainees and providers increases success at first attempt of intubation, decreases the number of attempts, decreases airway injury but does not decrease time to intubation. We 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.

Mike: 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'.