226 What Is the Effect of Training on the Performance of Different Video Laryngoscope Geometries Versus Direct Laryngoscopy to Achieve First Pass Success During Emergent Tracheal Intubation? A Systematic Review and Meta-Analysis

Abstract

We sought to perform a systematic review and meta-analysis of the effect of training on the performance of different video laryngoscope (VL) blade geometries to achieve first pass success (FPS) in the emergent setting in the emergency department, intensive care unit, or out-of-hospital setting. We searched MEDLINE, Embase, and Web of Science (from database inception until April, 2022) to identify observational and randomized controlled trial (RCT) studies that compared FPS among the VL blade geometries and included data on operator level of training. We excluded studies for not comparing blade geometries, studies performed in the operating theater, simulation studies, duplicate studies, and those containing no extractable data. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to assess the quality of included studies and used the Cochrane Risk of Bias Tool (RoB) to assess the risk of bias for the RCTs. Heterogeneity was assessed by the I2 statistic. Meta- analysis was performed using the Sidik and Jonkman random-effects model, and the results are reported as pooled odds ratios (OR) with 95% CI for FPS. We identified 1530 studies and excluded 1469; among the 61 included studies (75,583 total patients), 22 studies (36%) primarily had fellows or attendings in the intubating operators, 33 studies (54%) primarily had residents, and 6 (10%) primarily had out-of-hospital operators. Of the 61 studies, 10 (16.4%) were classified as having high quality evidence, 22 (36.1%) as moderate quality evidence, and 29 (47.5%) as low quality evidence using GRADE methodology. Among the 17 included RCTs, 8 (47.1%) were classified as having a low risk of bias using the RoB. In pairwise, random effects meta-analysis we found Macintosh-styled VL (MACVL) to be superior to DL for achieving FPS (OR = 1.66, 95% CI 1.36 -2.04, n = 27), as was hyperangulated VL (HAVL) (vs DL: OR = 1.82, 1.16 - 2.84, n = 27). MACVL and HAVL were comparable (OR = 0.94, 0.73 - 1.20, n = 4). For the studies with residents, MACVL was superior to DL (OR = 1.79, 1.40 - 2.28, n = 13). Similarly, for residents, HAVL was superior to DL (OR = 1.71, 1.21 - 2.42, n = 14). For the studies primarily with attendings, MACVL was comparable to DL (OR = 1.31, 0.96 - 1.77, n = 10); and for attendings, HAVL was also comparable to DL (OR = 2.34, 0.96 - 5.73, n = 11). For residents, HAVL was comparable to MACVL (OR = 0.94, 0.73 - 1.20, n = 4). There were no studies that directly compared HAVL to MACVL for attendings. Heterogeneity was moderate to high for all comparisons. Resident physicians, but not attending physicians, intubating in the emergency department, intensive care unit, and out-of-hospital settings were more likely to achieve FPS using either a MACVL or HAVL device compared to a DL device. Although our results should be interpreted with caution, this meta- analysis suggests there is either a ceiling effect of VL devices to achieve FPS when performed by attendings or that residents may be more proficient with VL devices than attendings. Future studies should report the intubating operator’s number of previous intubations to better quantify intubation experience as opposed to classifying experience based on attending or post-graduate year trainee status.