Journal Reading

Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal

intubation: A Cochrane Systematic Review

Oleh :

Anggita Luthfi Permatasari 2140312162

Teguh Bedi Putra 2140312012

Preseptor :

dr. Zulfikar, Sp.An

BAGIAN ANESTESI DAN TERAPI INTENSIF

FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS
RSUP DR M. DJAMIL PADANG
2022
 Videolaringoskopi versus laringoskopi langsung untuk orang dewasa pasien yang
membutuhkan intubasi trakea: Sebuah Tinjauan Sistematis dari Conchrane
S. R. Lewis, A. R. Butler, J. Parker, T. M. Cook, O. J. Schofield-Robinso and A. F. Smith

Abstrak
Kesulitan dengan intubasi trakea sering muncul dan berdampak pada keselamatan pasien.
Tinjauan sistematis ini mengevaluasi apakah videolaryngoscopes mengurangi kegagalan intubasi
dan komplikasi dibandingkan dengan laringoskopi langsung pada orang dewasa. Kami mencari
CENTRAL, MEDLINE, Embase dan clinicaltrials.gov hingga Februari 2015, dan melakukan
kutipan maju dan mundur pelacakan. Kami memasukkan uji coba terkontrol secara acak yang
membandingkan pasien dewasa yang menjalani laringoskopi dengan videolaringoskopi atau
laringoskopi Macintosh. Kami tidak bermaksud untuk membandingkan videolaringoskop
individu. Enam puluh empat studi (7044 peserta) dimasukkan. Bukti kualitas sedang
menunjukkan bahwa videolaringoskopi mengurangi kegagalan intubasi (Odds Ratio (OR) 0,35,
95% Confidence Interval (CI) 0,19-0,65) termasuk pada peserta dengan kesulitan jalan napas
yang diantisipasi (OR 0,28, 95% CI 0,15-0,55). Tidak ada bukti pengurangan hipoksia atau
kematian, tetapi beberapa penelitian melaporkan hasil ini. Videolaryngoscopes mengurangi
trauma laring / jalan napas (OR 0,68, 95% CI 0,48-0,96) dan suara serak (OR 0,57, 95% CI 0,36-
0,88). Videolaringoskopi meningkatkan tampilan laring yang mudah (OR 6.77, 95% CI 4.17-
10.98) dan mengurangi tampilan yang sulit (OR 0,18, 95% CI 0,13-0,27) dan kesulitan intubasi,
biasanya menggunakan 'skor kesulitan intubasi' (OR 7.13, 95% CI 3.12-16.31). Intubasi yang
gagal berkurang dengan operator yang berpengalaman (OR 0,32, 95% CI 0,13-0,75) tetapi tidak
dengan pengguna yang tidak berpengalaman. Kami mengidentifikasi tidak ada perbedaan dalam
jumlah upaya pertama dan kejadian sakit tenggorokan. Heterogenitas sekitar waktu untuk
intubasi data mencegah meta-analisis. Kami menemukan bukti kinerja yang berbeda antara
desain videolaringoskop yang berbeda. Kurangnya data mencegah analisis dampak obesitas atau
lokasi klinis pada tingkat kegagalan intubasi. Videolaringoskop mungkin mengurangi jumlah
intubasi yang gagal, terutama di antara pasien yang mengalami kesulitan jalan napas. Mereka
meningkatkan pandangan glotis dan dapat mengurangi trauma laring / jalan napas. Saat ini, tidak
ada bukti yang menunjukkan bahwa penggunaan videolaringoskop mengurangi jumlah upaya
intubasi atau kejadian hipoksia atau komplikasi pernapasan, dan tidak ada bukti yang

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menunjukkan bahwa penggunaan videolaringoskop mempengaruhi waktu yang dibutuhkan untuk
intubasi.

Kata Kunci
Anestesia, Hipoksia, Intubasi, Laringoskop

Pengantar
Data Inggris terbaru menunjukkan bahwa intubasi trakea digunakan untuk manajemen
jalan napas pada 38,4% anestesi umum, diperkirakan pada 1,1 juta prosedur per tahun.2 Intubasi
dengan laringoskopi langsung, membutuhkan fleksi tulang belakang leher bagian bawah dan
memperpanjang tulang belakang leher bagian atas untuk menciptakan 'garis pandang', dan pisau
Macintosh biasanya digunakan untuk menarik kembali lidah untuk memungkinkan lewatnya pipa
trakea. Intubasi yang gagal atau sulit dikaitkan dengan komplikasi, termasuk peningkatan risiko
hipertensi, desaturasi, penerimaan tak terduga ke unit perawatan intensif (ICU) dan kematian.3–5
Kesulitan seperti itu selama intubasi rutin terjadi pada 1-6% kasus dan intubasi gagal dalam 0,1-
0,3% kasus6,7 tetapi jauh lebih umum di ICU dan departemen darurat.8 Kesulitan intubasi
mungkin timbul dari pembatasan dalam fleksi leher, pembukaan rahang yang sempit, lidah yang
membesar, mobilitas jaringan yang buruk, atau ketidakstabilan serviks dan di Inggris, 4th
National Audit Project ke-4 (NAP-4) menunjukkan bahwa intubasi yang tertunda dan gagal
adalah prekursor penting komplikasi jalan napas utama.8 Sebuah pengamatan besar baru-baru ini
studi kohort mengidentifikasi 93% intubasi yang sulit sebagai hal yang tidak dapat diprediksi;
dan tes prediksi, misalnya Mallampati atau Tes indeks Wilson10,11 memiliki sensitivitas rendah
dan nilai prediksi positif.7
Alternatif untuk blade Macintosh bergantung pada serat optik atau teknologi digital untuk
mengirimkan gambar dari ujung laringoskop ke lensa mata atau monitor, dimana gambar
tersebut dilihat oleh mata intubator. Untuk ulasan ini, kami tertarik pada videolaringoskop yang
menggunakan pisau untuk menarik kembali jaringan lunak dan mengirimkan gambar video ke
layar yang terpasang di ujung menangani atau ke monitor. Desain ini memungkinkan pandangan
terang dari laring tanpa 'garis pandang' langsung dan karena itu dapat membantu ketika kesulitan
ditemui (atau diprediksi) dengan laringoskopi langsung. Studi menunjukkan bahwa penggunaan
videolaringoskop meningkatkan tampilan laring selama tindakan laringoskopi12,13 dan

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videolaringoskop karena itu memberikan kemungkinan lebih keberhasilan intubasi untuk pasien
yang laringoskopi langsung susah. Mereka juga dapat digunakan setelah upaya yang gagal untuk
intubasi dengan laringoskopi langsung. Sementara penggunaan videolaringoskop dapat
membantu visualisasi, bukti diperlukan untuk menetapkan apakah ini sama dengan peningkatan
keberhasilan intubasi trakea. dengan komplikasi yang berkurang. Tujuan utama kami adalah
untuk menilai apakah videolaringoskopi untuk intubasi trakea orang dewasa mengurangi risiko
komplikasi dan kegagalan dibandingkan dengan laringoskopi langsung. Tujuan sekunder kami
adalah untuk menilai manfaat dan risiko perangkat ini pada populasi tertentu, seperti: sebagai
orang dewasa dengan obesitas, pasien sakit kritis di ICU dan pengaturan darurat, dan mereka
yang diketahui atau diprediksi sulit jalan napas.

Metode
Protokol
Makalah ini melaporkan versi singkat dari yang diterbitkan sebelumnya Tinjauan sistematis
Cochrane sendiri berdasarkan protokol yang sebelumnya diterbitkan di database tinjaun sistemis
cochrane.14 Kami menyiapkan naskah ini sesuai dengan pedoman diterbitkan oleh Cochrane,15
PRISMA statement untuk sistematika ulasan dan meta-analisis,16 dan British Journal of
Anaesthesia guidelines
Sumber Informasi
Kami mencari di Cochrane Central Register of Controlled Trials (CENTRAL, Edisi 2, 2015),
MEDLINE (1970 hingga Februari 2015) dan Embase (1980 hingga Februari 2015). Kami sangat
menerapkan Cochrane filter sensitif untuk uji coba terkontrol secara acak di MEDLINE dan
Embase. Kami mencari database pendaftaran percobaan www.clinicaltrial.gov (diakses 19
Agustus 2014) untuk uji coba yang sedang berlangsung. Kami melakukan pelacakan kutipan ke
depan dari semua studi yang disertakan dan pelacakan kutipan mundur dari artikel ulasan yang
diidentifikasi. Kami menggunakan tidak ada batasan bahasa publikasi. Strategi pencarian
digunakan untuk MEDLINE dapat ditemukan di protokol ulasan.14
Kriteria Kelayakan
Kami memasukkan uji coba terkontrol secara acak (RCT), dengan paralel atau desain cross-over
yang membandingkan penggunaan model videolaringoskop apa pun dengan blade Macintosh
pada peserta berusia 16 tahun yang membutuhkan intubasi trakea selama anestesi.

4
Koleksi Data dan Analisis
Dua penulis ulasan secara independen menyaring judul dan abstrak hasil pencarian untuk
menghapus studi yang tidak relevan. Dua ulasan penulis kemudian meninjau teks lengkap dari
judul yang berpotensi relevan dan mengidentifikasi studi yang cocok dengan kriteria inklusi.
Data aktif karakteristik dan hasil studi secara independen diekstraksi dari studi yang memenuhi
syarat oleh dua dari tiga peneliti, untuk sertakan data untuk hasil berikut :
Hasil Utama
1. Intubasi gagal atau penggantian perangkat diperlukan (kegagalan karena didefinisikan oleh
penulis studi)
2. Hipoksia antara awal intubasi dan pemulihan dari anestesi
Hasil Sekunder
1. Kematian dalam waktu 30 hari setelah anestesi
2. Komplikasi saluran napas yang serius, termasuk aspirasi, dalam 30 hari anestesi
3. Trauma laring atau jalan napas, termasuk salah satu dari kerusakan untuk pita suara,
pendarahan atau cedera gigi
4. Pasien melaporkan sakit tenggorokan: awal (dalam dua jam anestesi) dan terlambat (dalam
48 jam anestesi)
5. Suara serak: awal (dalam waktu dua jam setelah anestesi) dan akhir (dalam 48 jam setelah
anestesi)
6. Proporsi upaya pertama yang berhasil di trakea intubasi
7. Jumlah upaya intubasi trakea
8. Total waktu untuk intubasi dan dimulainya ventilasi
9. Kesulitan intubasi: dinilai oleh pengamat atau intubator, menggunakan skala yang diturunkan
secara lokal atau divalidasi
10. Peningkatan visualisasi laring : dinilai menggunakan sistem klasifikasi yang divalidasi.12,17,18
Risiko Bias dalam Studi
Kami menggunakan alat risiko bias cochrane untuk menilai kualitas desain studi dan
tingkat bias potensial dan mempertimbangkan domain berikut: generasi urutan, penyembunyian
alokasi, membutakan peserta, personel dan penilai hasil, data yang tidak lengkap, dan pelaporan
hasil selektif.15 Itu tidak mungkin untuk membutakan intubator terhadap intervensi, atau
membutakan penilai dari langkah-langkah proses. Namun, membutakan pasien dan penilai hasil

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pasca-intervensi untuk jenis perangkat adalah layak.
Ringkasan langkah-langkah dan sintesis hasil
Data dianalisis menggunakan Review Manager, versi 5.3.19 hasil dikotomis (misalnya
gagal intubasi, hipoksia, kematian) kami menghitung odds ratio (OR) dengan interval
kepercayaan 95% (CI). Untuk pengukuran terus menerus (waktu untuk intubasi) kami
menghitung perbedaan rata-rata (MD). Kami mencatat beberapa hasil di skala ordinal pendek
(yaitu jumlah upaya, skor kesulitan intubasi dan skala visualisasi yang ditingkatkan) dan
dikonversi ini ke data dikotomis jika sesuai. Untuk banyak penelitian, kami menggunakan
kelompok pembanding gabungan (menggabungkan semua videolaringoskop) dibandingkan
dengan kelompok kontrol, untuk membuat perbandingan berpasangan tunggal.15 Ketika tidak
mungkin untuk menggabungkan data tanpa unit kesalahan analisis, kami termasuk data dari
kelompok videolaringoskop yang akan paling dekat dengan memberikan hasil 'tidak
berpengaruh'; keputusan ini kemudian dibahas dalam analisis sensitivitas.
Kami melakukan meta-analisis untuk hasil yang kami memiliki ukuran efek yang
sebanding dari lebih dari satu studi dan dimana ukuran heterogenitas klinis, metodologis dan
statistik menunjukkan bahwa penyatuan hasil adalah tepat. Kami diklasifikasikan tingkat
heterogenitas statistik menggunakan statistik I2 menurut Higgins.15 Kami menganggap bahwa
nilai I2<40% akan tidak menunjukkan heterogenitas penting dan di atas 75% akan menjadi
substansial.15 Pilihan kami untuk efek tetap atau efek acak model statistik untuk setiap meta-
analisis dipengaruhi oleh studi karakteristik, khususnya jumlah metodologis atau perbedaan
klinis antara studi. Kami menggunakan Mantel-Haenszel model untuk semua hasil dikotomis.
Untuk hasil kontinu, kami menggunakan metode varians terbalik.
Kami bertujuan untuk melakukan analisis subkelompok untuk menilai apakah hasil meta-
analisis berbeda menurut: desain videolaringoskop yang berbeda; laringoskopi sulit diantisipasi
atau diketahui; pengalaman intubator (operator 'berpengalaman' harus memiliki melakukan
setidaknya 20 intubasi dengan perangkat); gemuk dan peserta non-obesitas; dan tempat intubasi
(operasi) teater, departemen darurat atau ICU). Kami melakukan analisis sensitivitas untuk
mengeksplorasi dampak data yang hilang pada kami hasil dan keputusan yang dibuat selama
penilaian risiko bias dan analisis data. Kualitas bukti untuk masing-masing atau hasil kami
adalah dinilai menggunakan sistem GRADE.20 Penjelasan lengkap tentang bagaimana ini
dilakukan, dan mengapa bukti diturunkan, ada di versi Cochrane asli.1

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Hasil
Pemilihan dan Karakteristik Studi
Kami mengidentifikasi 4920 judul dan abstrak dari pencarian database (10 Februari
2015) dan melalui pelacakan kutipan maju dan mundur. Setelah penghapusan duplikat, kami
menyaring 3412 judul dan abstrak dan menilai 275 teks lengkap untuk kelayakan. Kami
mengidentifikasi 64 RCT (dengan 7044 peserta)21-84 Beberapa desain laringoskop dapat
digunakan dengan dan tanpa lampiran kamera (seperti Airtraq dan Truview EVO2) dan kami
mengecualikan studi jika penglihatan langsung tanpa lampiran kamera dan layar terpisah
digunakan, atau yang tidak jelas dari laporan yang diterbitkan jika kamera perangkat dan layar
telah digunakan; studi yang dikecualikan adalah dilaporkan dalam versi lengkap ulasan
Cochrane.1 Kami mengidentifikasi lima abstrak yang informasinya tidak mencukupi,100–105 dan
tiga teks lengkap yang memerlukan terjemahan yang tidak dapat kami lakukan.105-107 Melalui
klinis kami pencarian register percobaan, kami juga mengidentifikasi tujuh studi yang sedang
berlangsung,85-91 dan delapan studi lebih lanjut yang datanya belum ada telah diterbitkan.92–99
Satu penelitian berlangsung di ICU,38 satu dalam keadaan darurat departemen,84 dan satu
di luar rumah sakit,26 semuanya dengan peserta yang membutuhkan perawatan darurat. Sisanya
61 penelitian berlangsung di pengaturan ruang operasi rumah sakit dengan peserta bedah elektif.
Dua penelitian menyebutkan inklusi hanya peserta obesitas,21 23 satu studi hanya memasukkan
peserta,25 satu studi hanya peserta dengan tidak diobati hipertensi,35 dan satu studi hanya peserta
dari luka bakar unit.82 Kami memasukkan tiga penelitian yang menggunakan tabung trakea
lumen ganda untuk intubasi.28,34,69 Semua penelitian lainnya menggunakan tabung lumen
tunggal. Sembilan jenis desain videolaringoskop digunakan dalam 64 studi yang disertakan:
GlideScope (Verathon UK, Amersham UK), Pentax AWS (Pentax, Tokyo, Jepang), C-MAC
(termasuk laringoskop DCI yang merupakan pendahulunya) dengan pisau Macintosh (Karl Storz,
Slough UK), McGrath Series 5 (Aircraft Medical, Edinburgh, UK), X-lite (Rush, Tuttlingen,
Jerman), C-MAC D-blade (Karl Storz, Slough UK), Airtraq (Prodol Meditec, Guecho, Spanyol),
Truview EVO2 (Truphatek International Ltd., Netanya, Israel), dan CEL-100 (Connell Energy
Technology Co. Ltd., Shanghai, Tiongkok). Sebagian besar studi membandingkan penggunaan
GlideScope, Pentax AWS, blade C-MAC Macintosh dan McGrath Series 5. Kami
mengidentifikasi 17 studi yang dilakukan dengan desain crossover studi dengan desain paralel.
Studi-studi yang dijelaskan oleh penulis studi sebagai desain cross-over menggunakan satu jenis

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laringoskop awalnya untuk menilai tampilan glotis, diikuti oleh jenis laringoskop lainnya untuk
menilai pandangan glotis dan melakukan intubasi. Pengecualian untuk ini adalah satu penelitian,
yang mengintubasi peserta setelah laringoskopi dengan masing-masing perangkat.40 Peserta di
kedua cross-over desain diacak dengan urutan yang berbeda dari laringoskop.
Empat puluh tujuh penelitian termasuk peserta tanpa kesulitan jalan napas yang
diprediksi, dan 15 dari teknik ini digunakan untuk mensimulasikan jalan napas yang sulit untuk
tujuan penelitian. Enam studi merekrut peserta dengan kesulitan jalan napas yang diketahui atau
diprediksi, tetapi yang lain tidak menentukan atau memasukkan pasien dengan keduanya
diprediksi dan tidak diprediksi sulit saluran udara. Empat puluh tujuh penelitian menyebutkan
bahwa ahli anestesi berpengalaman melakukan laringoskopi. Lima penelitian menggunakan ahli
anestesi yang digambarkan sebagai: pemula atau yang dilatih dengan manekin tetapi tidak
memiliki pasien pengalaman. Lima penelitian menggunakan anestesi pemula dan
berpengalaman. Tujuh penelitian tidak menentukan pengalaman ahli anestesi. Karakteristik studi
terperinci dilaporkan dalam versi lengkap tinjauan Cochrane.1

Hasil Utama
Intubasi Gagal
Hasil ini didefinisikan dalam tinjauan sebagai definisi yang digunakan oleh penulis penelitian.
Definisinya adalah tercantum dalam 'Tabel Studi yang Disertakan' di publikasi Versi Cochrane,1
tetapi biasanya menyertakan tindakan berdasarkan: waktu (biasanya lebih besar dari 60 atau 120
detik) atau jumlah percobaan (kegagalan biasanya didefinisikan sebagai ketidakmampuan untuk
mengintubasi trakea) dalam dua atau tiga upaya). Tiga puluh delapan penelitian dengan peserta
melaporkan jumlah intubasi yang gagal. Kami mengecualikan satu studi crossover40 dari meta-
analisis yang memperkenalkan terlalu banyak bias kinerja menjadi setara dengan yang lain.
Analisis menunjukkan lebih sedikit intubasi yang gagal saat videolaryngoscope digunakan (OR,
efek acak 0,35, 95% CI 0,19 hingga 0,65; I2 52%; n¼ 4127). Bukti dari plot corong untuk hasil ini
menyarankan bahwa tidak ada bukti bias pelaporan.
Hipoksia.
Delapan penelitian melaporkan hipoksia dan hanya tiga di antaranya yang memiliki data
kejadian.27-29 Analisis menunjukkan tidak ada perbedaan hipoksia menurut jenis perangkat (OR,
efek acak 0,39, 95% CI 0,10 hingga 1,44; I2 70%; n¼1319).

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Hasil sekunder
Kematian.
Hanya dua penelitian yang melaporkan tingkat kematian. Satu studi38 berbasis di ICU dan satu84
di unit gawat darurat dengan tidak ada perbedaan jumlah kematian menurut jenisnya perangkat
(OR, efek tetap 1,09, 95% CI 0,65 hingga 1,82; I2 29%; n¼ 663)
Komplikasi saluran napas yang serius.
Hanya satu penelitian yang melaporkan pernapasan komplikasi sebagai hasil dengan satu
kejadian pneumotoraks yang tercatat pada kelompok Macintosh dan tidak ada pada kelompok
videolaringoskop.30
Trauma laring/jalan napas.
Dua puluh sembilan studi melaporkan data untuk trauma laring atau jalan napas, atau keduanya.
Kami melakukan metaanalisis dari 22 perbandingan dengan data peristiwa. Hasilnya
menunjukkan lebih sedikit peristiwa trauma ketika videolaryngoscope digunakan (OR, efek acak
0,68, 95% CI 0,48 hingga 0,96; I2 25%; n¼ 3110)
Sakit tenggorokan atau suara serak.
Tujuh belas penelitian dengan 2.392 peserta melaporkan sakit tenggorokan atau suara serak, atau
keduanya. Kami membangun analisis untuk studi di dua titik waktu: di unit perawatan pasca
anestesi (PACU) dan di 24 jam Enam penelitian tidak menyatakan kapan sakit tenggorokan
dinilai dan untuk tujuan analisis ini kami memasukkan data ini ke dalam Kelompok PACU.
Analisis menunjukkan tidak ada perbedaan insiden sakit tenggorokan di PACU (OR, efek acak
1,00, 95% CI 0,73 hingga 1,38; I2 24%; n¼1548) atau pada hari pertama pasca operasi menurut
jenis perangkat (OR, efek acak 0,54, 95% CI 0,27 hingga 1,07; I2 74%; n¼ 844) Enam studi
melaporkan data untuk suara serak. Kami menggabungkan data terlepas dari waktu pengukuran.
Ada lebih sedikit insiden suara serak bagi mereka yang menggunakan videolaringoskop telah
digunakan (OR, efek tetap 0,57, 95% CI 0,36 hingga 0,88; I2 28%; n¼ 527).
Proporsi penempatan pertama yang berhasil.
Kami menggabungkan data dari 36 studi untuk upaya pertama yang berhasil. Analisis
menunjukkan tidak ada perbedaan dalam jumlah percobaan pertama yang berhasil menurut jenis
perangkat (OR, efek acak 1,27, 95% CI 0,77 hingga 2,09; I2 79%; n¼ 4731)

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Jumlah percobaan.
Tiga puluh studi melaporkan jumlah percobaan sebagai hasil dan kami dapat menggabungkan
data untuk 28 studi. Analisis tidak menunjukkan perbedaan antara jenis perangkat untuk itu
peserta diintubasi dalam satu upaya (OR, efek acak 1,25, 95% CI 0,68 hingga 2,31; I2 79%;
nomor 3346). Kami menggabungkan data dari studi yang melaporkan dua, tiga atau empat
upaya, dan di sana tidak ada perbedaan antara jenis laringoskop dengan tambahan upaya (OR,
efek acak 0,89, 95% CI 0,47 hingga 1,70; I2 79%; n¼ 3346).
Waktu untuk intubasi trakea.
Lima puluh lima penelitian melaporkan waktu untuk intubasi trakea. Dari jumlah tersebut, 18
dikeluarkan dari formal analisis karena unit masalah analisis. Yang tersisa 37 studi termasuk
studi multi-lengan dengan total 44 perbandingan. Kami mengidentifikasi tingkat heterogenitas
statistik yang sangat tinggi (I2 96%) ketika 37 studi ini digabungkan, mungkin dijelaskan oleh
berbagai titik waktu di mana studi individu diukur hasil ini. Oleh karena itu, kami belum
menyajikan perkiraan efek untuk waktu intubasi.
Kesulitan intubasi.
Sembilan belas studi dengan 1765 peserta melaporkan kesulitan intubasi trakea. Empat belas
menggunakan skala pengukuran tervalidasi yang sama Skor Kesulitan Intubasi di antaranya kami
dapat menggabungkan tujuh studi. Analisis menunjukkan bahwa videolaringoskop lebih mudah
untuk gunakan bila dibandingkan dengan Macintosh, dengan 165 dari 340 kasus diberi skor IDS
terendah 0 di videolaringoskop kelompok, 31 dari 228 kasus pada kelompok Macintosh (OR,
efek acak 7,13, 95% CI 3,12 hingga 16,31; I2 62%; n¼568). Dari studi yang tersisa yang
menggunakan sistem penilaian IDS, empat melaporkan hasil yang signifikan secara statistik
mendukung videolaryngoscope. Lima studi menggunakan skala alternatif untuk IDS, dengan
perbedaan dalam arah efek dilaporkan antara studi.
Visualisasi yang ditingkatkan.
Tiga puluh enam studi menilai visualisasi menggunakan sistem penilaian Cormack dan Lehane
(CL)12 dan kami mampu melakukan meta-analisis dalam 22 studi. Ini menunjukkan jumlah
laringoskopi yang lebih tinggi yang mencapai tampilan CL grade 1 (yaitu lebih dari 50% terlihat)
ketika videolaringoskop digunakan (OR, efek acak 6,77, 95% CI 4,17 hingga 10,98; I274%; n¼
2240). Kami dengan data gabungan untuk CL kelas 1 hingga 2 dan untuk kelas 3 hingga 4. Ini
juga menunjukkan lebih banyak laringoskopi mencapai CL grade 1 atau 2 dengan

10
videolaringoskop (OR, efek acak 5,42, 95% CI 3,70 sampai 7,95; I2 5%; n¼2240), dan lebih
sedikit laringoskopi videolaringoskop yang mencapai CL grade 3 atau 4 (OR, efek acak 0,18,
95% CI 0,013 sampai 0,27; I2 5%; n¼ 2240). Ada lima penelitian yang menggunakan metode
penilaian POGO (persentase pembukaan glotis).33,40,65,70,82 Hasil gabungan menunjukkan
heterogenitas yang sangat tinggi (I2 96%) dan oleh karena itu data tidak dikumpulkan.
Analisis tambahan - Analisis sub-grup
Desain videolaringoskop
Dari empat desain videolaringoskop dengan data yang cukup untuk meta-analisis, tiga
(GlideScope, Pentax atau McGrath Series 5) menunjukkan tidak ada perbedaan dalam jumlah
intubasi yang gagal dibandingkan dengan blade Macintosh (GlideScope: OR, efek acak 0,57,
95% CI 0,25 hingga 1,32; I2 24%; n¼1306, Pentax: OR, efek acak 0,24, 95% CI 0,05 hingga
1,20; I2 59% n¼1086, McGrath Seri 5 OR, efek acak 1,18, 95% CI 0,06 hingga 23,92; I2 78%; n¼
466) sementara dengan blade CMAC Macintosh ada pengurangan kegagalan intubasi trakea
(OR, efek acak) 0,32, 95% CI 0,15 hingga 0,68; I2 0%; n¼1058)
Intubasi sulit yang diantisipasi atau diketahui
Ada lebih sedikit kegagalan intubasi ketika videolaringoskop digunakan dengan peserta yang
memiliki kesulitan jalan napas yang diprediksi (OR, efek acak 0,28, 95% CI 0,15 hingga 0,55; I2
0%; n¼ 830) atau a simulasi jalan napas yang sulit (OR, efek acak 0,18, 95% CI 0,04 ke 0,77; I2
53%; n¼ 810). Tidak ada perbedaan dalam kegagalan intubasi berdasarkan jenis perangkat untuk
peserta tanpa kesulitan yang diprediksi jalan napas (OR, efek acak 0,61, 95% CI 0,22 hingga
1,67; I2 56%; n¼ 1743)
Pengalaman intubator
Kami membandingkan studi yang melibatkan personel berpengalaman (mis. 20 intubasi pasien
dengan masing-masing perangkat) dengan studi yang menggunakan intubator yang tidak
berpengalaman dengan videolaringoskop (<20 intubasi; atau tidak terbiasa menggunakan lumen
ganda tabung untuk intubasi). Studi dengan personel yang berpengalaman dalam kedua
perangkat memiliki lebih sedikit intubasi yang gagal ketika videolaringoskop digunakan (OR,
efek acak 0,32, 95% CI 0,13 hingga 0,75; I2 47%; n¼1927), tetapi tidak ada bukti perbedaan
dalam intubasi gagal ketika personel tidak berpengalaman dengan videolaringoskop (OR, efek
acak 0,20, 95% CI 0,02 hingga 2,56; I2 75%; n¼3 46)

11
Peserta obesitas dan non-obesitas
Kami mengidentifikasi dua studi21,23 yang menyertakan peserta obesitas. Hanya satu studi23 yang
menyertakan data untuk hasil utama kami dan oleh karena itu tidak layak untuk melakukan
analisis subkelompok terhadap studi dengan peserta non-obesitas.
Tempat intubasi yang berbeda
Kami mengidentifikasi tiga studi26,38,84 yang berada dalam keadaan darurat atau pengaturan pra-
rumah sakit. Hanya satu studi26 termasuk data untuk hasil utama kami dan oleh karena itu tidak
layak untuk melakukan analisis subkelompok terhadap studi dalam pengaturan elektif.
Analisis tambahan - Analisis sensitivitas
Untuk menyelidiki kekokohan bukti, kami melakukan empat analisis sensitivitas terpisah: data
yang hilang, cross-over studi, studi multi-lengan, dan risiko bias.
• Kami menghapus studi yang tidak dapat kami nilai apakah data sudah lengkap dan studi
yang kehilangan peserta lebih dari 10% atau kehilangan peserta tidak dapat dijelaskan.15
Interpretasi perkiraan efek tetap tidak berubah untuk semua hasil kecuali untuk sakit
tenggorokan pada hari 1 pasca operasi, di mana penghapusan satu studi 82 terungkap
lebih sedikit sakit tenggorokan ketika videolaryngoscope digunakan (OR, efek acak 0,45,
95% CI 0,22 hingga 0,90).
• Setelah penghapusan studi cross-over, tidak ada perbedaan hasil untuk semua hasil
kecuali laring/jalan napas trauma yang tidak lagi signifikan secara statistik (OR, efek
acak 0,75, 95% CI 0,51 hingga 1,11).
• Ulasan ini mencakup sejumlah studi multi-lengan yang membandingkan lebih dari satu
videolaringoskop terhadap macintosh. Kami menghindari kesalahan unit analisis di utama
kami analisis dengan memilih data hasil dalam studi multi-lengan untuk desain
videolaringoskop yang memiliki acara terendah tarif. Kami menggunakan analisis
sensitivitas untuk menilai efek dari keputusan ini dengan memilih data hasil untuk
videolaringoskop desain yang memiliki tingkat acara tertinggi. Perkiraan efek tetap tidak
berubah untuk semua hasil kecuali trauma laring / jalan napas yang tidak lagi secara
statistik signifikan (OR, efek acak 0,73, 95% CI 0,52 hingga 1,03).
• Kami mempertimbangkan dampak risiko penilaian bias kami terhadap hasil utama kami
dari intubasi gagal. Menghapus studi yang memiliki risiko bias seleksi yang tidak jelas
atau tinggi tidak secara signifikan mempengaruhi hasil (M-H OR, efek tetap 0,41, 95%

12
 CI 0,26 hingga 0,63; 23 studi; 2811 peserta). Demikian pula, menghapus studi yang
memiliki risiko tinggi bias gesekan mengakibatkan tidak ada perubahan signifikan dalam
perkiraan efek (M-H OR, efek tetap 0,36, 95% CI 0,26 hingga 0,51; 34 studi; n 3624).

Diskusi
Ringkasan hasil utama
Kami menemukan 64 studi yang membandingkan videolaringoskopi dengan direct
laringoskopi pada pasien yang membutuhkan intubasi trakea untuk anestesi umum. Analisis 38
studi, termasuk semua jenis videolaryngoscope, ditunjukkan secara statistik secara signifikan
lebih sedikit intubasi yang gagal ketika videolaryngoscope digunakan. Namun, ketika analisis
dilakukan berdasarkan jenis videolaringoskop, hanya bilah CMAC Macintosh yang
menunjukkan penurunan yang signifikan secara statistik pada kegagalan intubasi sedangkan
untuk intubasi gagal. GlideScope, Pentax atau McGrath Series 5 kami tidak menemukan secara
statistik perbedaan yang signifikan. Intubasi yang gagal secara signifikan lebih sedikit ketika
videolaringoskop digunakan pada peserta dengan jalan napas sulit yang diantisipasi (dalam
banyak kasus ditentukan oleh Skor Mallampati 3 atau 4) atau simulasi jalan nafas yang sulit,
sementara tidak ada perbedaan dalam intubasi yang gagal pada peserta yang datang tanpa
antisipasi kesulitan jalan napas. (Di dalam hormat, kami akan mencatat bahwa ada risiko yang
signifikan dari tipe 2 kesalahan dalam 'diprediksi mudah' karena intubasi gagal jarang terjadi dan
beberapa penelitian mencakup semua pasien dengan risiko tinggi di atas 'normal'). Kami juga
menemukan bahwa ada lebih sedikit intubasi yang gagal menggunakan videolaringoskop ketika
intubator memiliki pengalaman yang setara dengan kedua perangkat, tetapi tidak ketika intubator
berpengalaman dengan Macintosh tetapi tidak videolaringoskop.
Analisis hasil lainnya ditunjukkan secara statistik secara signifikan lebih sedikit trauma
laring / jalan napas dan lebih sedikit insiden suara serak pasca operasi ketika videolaryngoscope
digunakan. Namun, seperti dalam semua tinjauan sistematis, temuan mengikuti sebagian dari
keputusan yang dibuat selama proses peninjauan.108 Disini, hasil untuk trauma laring/saluran
napas bergantung pada keputusan kami untuk memasukkan desain cross-over dan data mana
yang akan digunakan untuk studi multi-lengan yang disertakan. Saat menggunakan
videolaryngoscope, dibandingkan dengan laringoskopi Macintosh ada jumlah laringoskopi yang
secara statistik lebih tinggi mencapai tampilan kelas 1 Cormack dan Lehane, dan tampilan kelas

13
1-2 dan lebih sedikit mencapai tampilan kelas 3-4. Videolaringoskop adalah lebih mudah
digunakan daripada Macintosh. Sebaliknya, orang bisa berdebat bahwa tingkat heterogenitas
(apakah itu muncul dari masalah dengan definisi hasil, protokol studi, dll.) dalam studi rinci
terlalu tinggi untuk melakukan meta-analisis sama sekali.
Kami memilih untuk melakukannya, tetapi telah menarik perhatian pada kualitas bukti
yang umumnya rendah selama presentasi tinjauan ini. Hanya ada tiga penelitian yang
melaporkan hasil yang kami mampu bergabung untuk hipoksia. Untuk hasil ini, tidak ada
perbedaan antara jenis perangkat yang digunakan. Demikian pula, ada beberapa studi
melaporkan kematian dan komplikasi pernapasan. Fakta bahwa sebagian besar penelitian
dilakukan dalam pengaturan elektif di mana semua komplikasi ini jarang atau jarang terjadi
mempengaruhi temuan ini. Tidak ada yang signifikan secara statistik perbedaan kejadian sakit
tenggorokan baik di PACU atau di 24 jam pasca operasi. Tidak ada perbedaan yang signifikan
secara statistik antara perangkat dalam proporsi pertama yang berhasil upaya, atau pada mereka
yang membutuhkan lebih dari satu upaya. Disana adalah tingkat heterogenitas yang sangat tinggi
ketika mempelajari waktu yang dilaporkan untuk intubasi trakea digabungkan, mungkin
dijelaskan oleh berbagai titik waktu yang digunakan untuk mengukur hasil ini dan sebagai
hasilnya, kami tidak menyajikan perkiraan efek untuk hasil ini.
Itu tidak mungkin untuk membutakan personel dengan jenis laringoskop yang digunakan;
kami percaya bahwa semua studi tunduk pada nilai yang tinggi tingkat bias kinerja karena
potensi preferensi pengguna. Namun, kami mempertimbangkan jenis bias lain dalam analisis
sensitivitas kami, dan meskipun berbagai tingkat bias di seluruh studi, hasil untuk hasil utama
kami dari kegagalan intubasi tidak dipengaruhi oleh kualitas bukti ketika digabungkan dalam
metaanalisis. Saat menggunakan GRADE untuk menilai kualitas di seluruh termasuk studi, kami
percaya bahwa tingkat tinggi yang tidak dapat dihindari bias kinerja di semua studi harus
mengambil preferensi ketika risiko bias untuk ulasan ini dirangkum. Akibatnya, kami
menurunkan bukti untuk masing-masing hasil kami dengan satu tingkat untuk keterbatasan studi.
Kami menilai hasil intubasi gagal, proporsi yang berhasil terlebih dahulu upaya, dan sakit
tenggorokan, menjadi bukti kualitas moderat. Kami termasuk beberapa penelitian yang
melaporkan hipoksia, gangguan pernapasan serius, komplikasi, atau kematian, yang
menyebabkan ketidaktepatan; kami menurunkan hasil ini menjadi bukti kualitas yang sangat
rendah. Ada sejumlah besar penelitian dengan heterogenitas substansial yang melaporkan waktu

14
untuk intubasi trakea dan kami menurunkan bukti untuk hasil ini menjadi kualitas yang sangat
rendah. Kita temuan konsisten dengan ulasan terbaru109–111 yang menunjukkan bahwa perbaikan
ini lebih jelas pada pasien dengan kesulitan jalan napas,109 dan yang merekomendasikan
penggunaan videolaringoskop untuk mencapai keberhasilan intubasi pada pasien dengan risiko
laringoskopi yang lebih sulit.112
Keterbatasan
Kami mengecualikan studi yang telah menggunakan perangkat tertentu (seperti
laringoskop Airtraq dan Truview EVO2) dan tidak dijelaskan dalam laporan penelitian apakah
ini digunakan dengan lampiran video/kamera; karena kami hanya bermaksud memasukkan studi
di mana layar (tampilan tidak langsung) telah digunakan, oleh karena itu kami dikeluarkan 38
studi tersebut dari review. Kami mengalami kesulitan dalam menetapkan tingkat pengalaman
personel yang sebenarnya, baik berdasarkan jumlah tahun pengalaman yang relevan atau jumlah
pengalaman menggunakan setiap perangkat; meskipun kami berusaha untuk mengukur hasil
ulasan berdasarkan tingkat pengalaman, hasil kami hanya berlaku menurut interpretasi kita
sendiri tentang ini. Jika studi masa depan harus dilakukan dengan kesepakatan universal hasil
dan definisi dari hasil tersebut, 'kemudahan penggunaan' dan nilai studi itu sendiri dan meta-
analisis masa depan akan ditingkatkan.
Penggunaan videolaringoskop dalam skenario klinis tertentu belum cukup dieksplorasi
dalam ulasan ini, misalnya dalam pengaturan darurat selama anestesi, dan di ICU, gawat darurat
dan di luar rumah sakit. Kami tidak dapat secara berguna membedakan perbedaan kinerja antara
videolaringoskop yang berbeda, tetapi tidak mungkin perangkat dengan desain yang berbeda
semuanya berkinerja sama. Kami berlari kembali pencarian pada Januari 2016, sebelum
publikasi Cochrane versi ulasan ini, dan mengetahui tambahan yang diterbitkan studi yang belum
dimasukkan di sini dan studi yang sedang berlangsung diidentifikasi dalam pencarian register uji
klinis. Ini menunjukkan melanjutkan minat penelitian di bidang ini, dan penggabungan data dari
studi ini, selama pembaruan Cochrane formal, mungkin menyebabkan perubahan dalam hasil
tinjauan ini.
Implikasi untuk penelitian
Meskipun ada sejumlah besar penelitian dalam tinjauan sistematis ini, sehingga
menghindari beberapa kesulitan tinjauan dengan data yang jarang,114 kesimpulannya harus
dibatasi oleh variabilitas definisi yang digunakan (misalnya, untuk intubasi yang gagal),

15
pengaturan dan perangkat. Hal ini telah menimbulkan heterogenitas yang cukup besar dan,
bersama-sama dengan metodologi yang terbatas kualitas beberapa penelitian, berarti bahwa
hasilnya harus ditafsirkan dengan hati-hati. Jelas bahwa penelitian jalan napas di masa depan
harus menggunakan hasil dan prosedur standar. Dalam penelitian perawatan perioperatif, upaya
baru-baru ini telah dilakukan untuk membakukan definisi115 dan kami akan menyambut yang
serupa percobaan dalam penelitian jalan napas. Sebuah editorial yang akan datang di Jurnal juga
akan membahas ini.116 Ada juga kekurangan yang mencolok dari studi pada pasien berisiko
tinggi (mereka yang umumnya sulit untuk intubasi, bukan dengan reposisi, pemasangan kerah
serviks, dll.)117 dan pasien dalam pengaturan berbeda (berisiko tinggi) seperti unit gawat darurat
atau ICU. Lebih jauh studi langsung membandingkan videolaryngoscopes dari yang berbeda
jenis juga akan diterima.

Kesimpulan dan implikasi untuk praktik

Bukti kami menunjukkan bahwa videolaryngoscopes mengurangi kegagalan intubasi dan
membuat intubasi lebih mudah, terutama pada pasien dengan jalan napas sulit diprediksi atau
diketahui. Penggunaannya cenderung meningkatkan tampilan glotis dan mengurangi jumlah
laringoskopi di mana glotis tidak dapat dilihat, terlepas dari prediksi atau kesulitan yang
diketahui, dan dapat mengurangi kejadian laring / trauma jalan napas. Kami tidak menemukan
bukti yang menunjukkan bahwa penggunaan videolaryngoscope akan menghasilkan lebih sedikit
upaya untuk intubasi. Kami tidak dapat menentukan apakah intubasi cenderung mengambil lebih
sedikit atau lebih banyak waktu dengan videolaringoskop, atau apakah ini akan menghasilkan
lebih sedikit insiden hipoksia atau pernapasan komplikasi.

16
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 British Journal of Anaesthesia, 119 (3): 369–83 (2017)

doi: 10.1093/bja/aex228
Review Article

Videolaryngoscopy versus direct laryngoscopy for adult

patients requiring tracheal intubation: a Cochrane
Systematic Review†
S. R. Lewis1,*, A. R. Butler1, J. Parker2, T. M. Cook3,4, O. J. Schofield-Robinson1
and A. F. Smith5
1
Patient Safety Research Department, Royal Lancaster Infirmary, Lancaster, UK, 2Department of
Gastroenterology, Royal Bolton Hospital, Bolton, UK, 3Department of Anaesthesia, Royal United Hospitals
Bath, NHS Foundation Trust, Bath, UK, 4School of Clinical Sciences, University of Bristol, Bristol, UK and
5
Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
*Corresponding author. E-mail: Sharon.Lewis@mbht.nhs.uk
†
This review is an abridged version of a Cochrane Review previously published in the Cochrane Database of Systematic Reviews 2016, Issue 11, DOI:
CD011136 (see www.cochranelibrary.com for information).1 Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback,
and Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review.

Abstract
Difficulties with tracheal intubation commonly arise and impact patient safety. This systematic review evaluates whether
videolaryngoscopes reduce intubation failure and complications compared with direct laryngoscopy in adults. We searched
CENTRAL, MEDLINE, Embase and clinicaltrials.gov up to February 2015, and conducted forward and backward citation
tracking. We included randomized controlled trials that compared adult patients undergoing laryngoscopy with videolar-
yngoscopy or Macintosh laryngoscopy. We did not primarily intend to compare individual videolaryngoscopes. Sixty-four
studies (7044 participants) were included. Moderate quality evidence showed that videolaryngoscopy reduced failed intuba-
tions (Odds Ratio (OR) 0.35, 95% Confidence Interval (CI) 0.19-0.65) including in participants with anticipated difficult airways
(OR 0.28, 95% CI 0.15-0.55). There was no evidence of reduction in hypoxia or mortality, but few studies reported these out-
comes. Videolaryngoscopes reduced laryngeal/airway trauma (OR 0.68, 95% CI 0.48-0.96) and hoarseness (OR 0.57, 95% CI
0.36-0.88). Videolaryngoscopy increased easy laryngeal views (OR 6.77, 95% CI 4.17-10.98) and reduced difficult views (OR
0.18, 95% CI 0.13-0.27) and intubation difficulty, typically using an ‘intubation difficulty score’ (OR 7.13, 95% CI 3.12-16.31).
Failed intubations were reduced with experienced operators (OR 0.32, 95% CI 0.13-0.75) but not with inexperienced users. We
identified no difference in number of first attempts and incidence of sore throat. Heterogeneity around time for intubation
data prevented meta-analysis. We found evidence of differential performance between different videolaryngoscope designs.
Lack of data prevented analysis of impact of obesity or clinical location on failed intubation rates. Videolaryngoscopes may
reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the
glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a videolaryngoscope
reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indi-
cates that use of a videolaryngoscope affects time required for intubation.

Key words: anaesthesia; hypoxia; intubation; laryngoscopes

Editorial decision: June 7, 2017; Accepted: June 19, 2017

C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
V
For Permissions, please email: journals.permissions@oup.com

369
 370 | Lewis et al.

Editor’s key points
• The authors examined the evidential support for the
hypothesis that videolaryngoscopy reduces the inci-
dence of intubation failure and other complications.
• They found evidence supporting a reduction in the
incidence of intubation failure when using a videolar-
yngoscope, particularly in the context of a difficult
airway.
Methods
Protocol
This paper reports an abridged version of a previously published
Cochrane systematic review,1 itself based on a protocol previ-
ously published in the Cochrane Database of Systematic
Reviews.14 We prepared this manuscript according to guidelines
published by Cochrane,15 the PRISMA statement for systematic
reviews and meta-analysis,16 and the British Journal of
Anaesthesia guidelines.

Information source
We searched the Cochrane Central Register of Controlled Trials
Recent UK data suggest that tracheal intubation is used for air-
(CENTRAL, Issue 2, 2015), MEDLINE (1970 to February 2015) and
way management in 38.4% of general anaesthetics, estimated
Embase (1980 to February 2015). We applied the Cochrane highly
at 1.1 million procedures per yr.2 Intubation with direct lar-
sensitive filter for randomized controlled trials in MEDLINE and
yngoscopy, requires flexing the lower cervical spine and
Embase. We searched the trial registry database www.clinical
extending the upper cervical spine to create a ‘line of sight’,
trials.gov (accessed 19 August 2014) for ongoing trials. We car-
and a Macintosh blade is commonly used to retract the tongue
ried out forward citation tracking of all included studies and
to enable passage of a tracheal tube. Failed or difficult intuba-
backward citation tracking of identified review articles. We used
tion is associated with complications, including increased risk
no restriction on language of publication. The search strategy
of hypertension, desaturation, unexpected admissions to the
used for MEDLINE can be found in the review protocol.14
intensive care unit (ICU) and death.3–5 Such difficulties during
routine intubation occur in 1–6% of cases and failed intubation
in 0.1-0.3% of cases6 7 but are much more common in ICU and Eligibility criteria
the emergency department.8 Intubation difficulties may arise
We included randomized controlled trials (RCTs), with a parallel
from restrictions in neck flexion, narrow jaw opening,
or cross-over design that compared the use of any model of vid-
enlarged tongue, poor tissue mobility, or cervical instability
eolaryngoscope with a Macintosh blade in participants
and, in the UK, the 4th National Audit Project (NAP4) showed
aged16 yr who required tracheal intubation during general
that delayed and failed intubation were important precursors
anaesthesia.
of major airway complications.8 A recent large observational
cohort study identified 93% of difficult intubation as unpre-
dicted9; and predictive tests, for example the Mallampati or Data collection and analysis
Wilson index test10 11 have low sensitivity and positive predic-
Two review authors independently screened titles and abstracts
tive value.7
of search results to remove irrelevant studies. Two review
Alternatives to the Macintosh blade rely on fibreoptic or digi-
authors then reviewed full texts of potentially relevant titles
tal technology to transmit an image from the tip of the laryngo-
and identified studies that matched inclusion criteria. Data on
scope to an eyepiece or monitor, where it is viewed by the
study characteristics and outcomes were independently
intubator. For this review, we are interested in rigid videolar-
extracted from eligible studies by two of three investigators, to
yngoscopes, which use a blade to retract the soft tissues and
include data for the following outcomes.
transmit a video image to a screen attached to the end of the
handle or to a monitor. This design enables a lighted view of the
larynx without direct ‘line of sight’ and can therefore assist Primary outcomes
when difficulty is encountered (or predicted) with direct lar-
yngoscopy. Studies suggest that use of a videolaryngoscope 1. Failed intubation or change of device required (failure as
improves the view of the larynx during laryngoscopy12 13 and defined by the study authors)
videolaryngoscopes therefore provide the possibility of more 2. Hypoxia between start of intubation and recovery from
successful intubation for patients in whom direct laryngoscopy anaesthesia
is difficult. They also may be used after unsuccessful attempts
to intubate with direct laryngoscopy. Whilst the use of videolar-
yngoscopes may aid visualisation, evidence is required to estab- Secondary outcomes
lish if this equates with increased success of tracheal intubation 1. Mortality within 30 days of anaesthesia
with reduced complications. Our primary objective was to 2. Serious airway complications, including aspiration, within
assess whether videolaryngoscopy for tracheal intubation in 30 days of anaesthesia
adults reduces the risk of complications and failure compared 3. Laryngeal or airway trauma, including any one of damage
with direct laryngoscopy. Our secondary aim was to assess the to vocal cords, bleeding or dental injury
benefits and risks of these devices in selected populations, such 4. Patient reported sore throat: early (within two h of anaes-
as adults with obesity, critically ill patients in the ICU and emer- thesia) and late (within 48 h of anaesthesia)
gency setting, and those with a known or predicted difficult air- 5. Hoarseness: early (within two h of anaesthesia) and late
way. We did not intend to compare video devices directly. The (within 48 h of anaesthesia)
finished work was published in the Cochrane Library in 20161; 6. Proportion of successful first attempts at tracheal
an abridged version is presented here, with the full detailed intubation
review being available on line for further reference. 7. Number of attempts at tracheal intubation
 Videolaryngoscopy versus direct laryngoscopy for adult patients
8. Total time for intubation and commencement of
ventilation
9. Difficulty of intubation: assessed by observer or intubator,
using locally derived or validated scales
10. Improved visualisation of the larynx: assessed using a vali-
dated classification system.12 17 18
Risk of bias within studies
We used the Cochrane risk of bias tool to assess the quality of
study design and extent of potential bias and considered the fol-
lowing domains: sequence generation, allocation concealment,
blinding of participants, personnel and outcome assessors,
incomplete data, and selective outcome reporting.15 It was not
possible to blind the intubator to the intervention, nor to blind
assessors of process measures. However, blinding of patients
and post-intervention outcome assessors to the type of device
was feasible.
Summary measures and synthesis of results
Data were analysed using Review Manager, version 5.3.19 For
dichotomous outcomes (e.g. failed intubation, hypoxia, mortal-
ity) we calculated odds ratios (OR) with 95% confidence intervals
(CI). For continuous measures (time for intubation) we calcu-
lated mean differences (MD). We recorded some outcomes in
short ordinal scales (i.e. number of attempts, intubation diffi-
culty scores and scales of improved visualisation) and converted
these to dichotomous data where appropriate. For multi-arm
studies, we used an amalgamated comparison group (combin-
ing all videolaryngoscopes) compared with the control group, to
create a single pair-wise comparison.15 When it was not possi-
ble to amalgamate data without unit of analysis error, we
included data from the videolaryngoscope group that would be
closest to giving a result of ‘no effect’; these decisions were then
addressed in sensitivity analysis.
We carried out meta-analysis for outcomes for which we
had comparable effect measures from more than one study and
where measures of clinical, methodological and statistical het-
erogeneity indicated that pooling of results was appropriate. We
classified levels of statistical heterogeneity using the I2 statistic
according to Higgins.15 We considered that I2 values<40% would
not indicate important heterogeneity and above 75% would be
substantial.15 Our choice of a fixed-effect or random-effects
statistical model for any meta-analysis was influenced by study
characteristics, in particular the amount of methodological or
clinical differences between studies. We used Mantel-Haenszel
models for all dichotomous outcomes. For the continuous out-
come, we used the inverse variance method.
We aimed to perform subgroup analyses to assess if results
of meta-analyses differed according to: different designs of vid-
eolaryngoscope; anticipated or known difficult laryngoscopy;
experience of intubator (an ‘experienced’ operator had to have
performed at least 20 intubations with the devices); obese and
non-obese participants; and the site of intubation (operating
theatre, emergency department or the ICU). We performed sen-
sitivity analyses to explore the impact of missing data on our
results and decisions made during risk of bias assessment and
analysis of data.
The quality of the evidence for each or our outcomes was
assessed using the GRADE system.20 A full account of how this
was performed, and why evidece was downgraded, is in the
original Cochrane version.1
| 371
Results
Study selection and characteristics
We identified 4920 titles and abstracts from database searches
(10th February 2015) and through forward and backward cita-
tion tracking. After removal of duplicates, we screened 3412
titles and abstracts and assessed 275 full texts for eligibility.
We identified 64 RCTs (with 7044 participants) to include in the
review (Fig. 1).21–84 Some designs of laryngoscope can be used
with and without a camera attachment (such as Airtraq and
Truview EVO2) and we excluded studies if direct vision without
the camera attachment and separate screen was used, or in
which it was unclear from the published report if the camera
device and screen had been used; excluded studies are
reported in the full version of the Cochrane review.1 We identi-
fied five abstracts for which there was insufficient informa-
tion,100–105 and three full texts which required translations
which we were unable to perform.105–107 Through our clinical
trial register searches, we also identified seven ongoing stud-
ies,85–91 and a further eight studies for which data had not yet
been published.92–99
One study took place in the ICU,38 one in an emergency
department,84 and one in an out-of-hospital setting,26 all with
participants requiring emergency treatment. The remaining 61
studies took place in the hospital operating theatre setting with
elective surgical participants. Two studies specified inclusion of
only obese participants,21 23 one study included only obstetric
participants,25 one study only participants with untreated
hypertension,35 and one study only participants from the burns
unit.82 We included three studies that used a double-lumen tra-
cheal tube for intubation.28 34 69 All remaining studies used a
single-lumen tube. Nine types of videolaryngoscope design
were used in the 64 included studies: GlideScope (Verathon UK,
Amersham UK), Pentax AWS (Pentax, Tokyo, Japan), C-MAC
(including the DCI laryngoscope which was its predecessor)
with Macintosh blade (Karl Storz, Slough UK), McGrath Series 5
(Aircraft Medical, Edinburgh, UK), X-lite (Rush, Tuttlingen,
Germany), C-MAC D-blade (Karl Storz, Slough UK), Airtraq
(Prodol Meditec, Guecho, Spain), Truview EVO2 (Truphatek
International Ltd., Netanya, Israel), and CEL-100 (Connell Energy
Technology Co. Ltd., Shanghai, China). Most studies compared
the use of GlideScope, Pentax AWS, C-MAC Macintosh blade and
McGrath Series 5. We identified 17 studies conducted by a cross-
over design31 32 34 36 40 44 52 53 56 60 65 67 68 71 72 78 80 and 47 studies
with a parallel design. Those studies described by study authors
as cross-over designs used one type of laryngoscope initially to
assess glottic view, followed by the other type of laryngoscope
to assess glottic view and perform intubation. The exception to
this was one study, which intubated participants after laryngo-
scopy with each device.40 Participants in both cross-over
designs were randomized by different orders of laryngoscope.
Forty-seven studies included participants without a pre-
dicted difficult airway, and 15 of these used techniques to simu-
late a difficult airway for the purpose of the study. Six studies
recruited participants with a known or predicted difficult air-
way, but others did not specify or included patients with both
predicted and not predicted difficult airways. Forty seven stud-
ies specified that experienced anaesthetists performed laryng-
oscopies.21–27 29–35 37 39 40 43–47 49–53 55 57–60 62–64 66–67 69 71 72 74 75 77
79 80 82 83
Five studies used anaesthetists who were described as
novices or who were trained with manikins but had no patient
experience.38 41 42 78 81 Five studies used both novice and experi-
enced anaesthetists.28 48 54 68 84 Seven studies did not specify
the experience of anaesthetists.36 56 61 65 70 73 76 Detailed study
 372 | Lewis et al.

406 records identified through 4514 records Clinical trials register search 7 ongoing studies
backward and forward citation identified through
8 studies awaiting classification
searching database
searching 7 protocols for included studies

3412 records after duplicates

removed

3412 records 3129 records

screened excluded

211 full-text
articles excluded:

38 unclear if
scope used video
camera

15
videolaryngoscope
not compared to
Macintosh

9
videolaryngoscope
used for
nasogastric
intubation

149 wrong
population,
intervention,
outcomes, study
design

8 studies awaiting
classification:
5 abstracts with
insufficient detail

3 full-texts
283 full-text requiring
articles assessed translation to
for eligibility English

64 studies
included in
quantitative
synthesis
(meta-analysis)

Fig 1 Flow chart of search strategy.

 Videolaryngoscopy versus direct laryngoscopy for adult patients
characteristics are reported in the full version of the Cochrane
review.1
Risk of bias in included studies
All studies were described as randomized, with 36 studies pro-
viding sufficient detail of methods of randomization. Allocation
concealment was poorly reported in studies. Few studies were
prospectively registered with clinical trials registers and we
were unable to make judgements on risk of selective reporting
bias in unregistered studies. Performance and detection bias
was high in all studies because it was not possible to blind the
intubator and assessors of the primary outcome. There was a
low risk of attrition bias in more than three quarters of studies
and we were not concerned by influence of funding sources
from videolaryngoscope manufacturers for most of the studies.
We paid particular attention to whether the experience of the
intubator in the videolaryngoscope and Macintosh group was
equivalent within each study and believed there to be a low risk
of bias for about 50% of studies. Study reports provided inad-
equate detail for many of our risk of bias criteria and therefore
we were unable to make assessments for these studies (Fig. 2). A
more detailed summary of the risk of bias per included study is
presented graphically in the Supplementary Appendix S1.
Synthesis of results
Primary outcomes
Failed intubation. This outcome was defined within the review as
the definition used by the study authors. The definitions are
listed in the ‘Table of Included Studies’ in the published
Cochrane version,1 but typically included measures based on
time (usually greater than 60 or 120 s) or on number of attempts
(failure being usually defined as inability to intubate the trachea
in two or three attempts). Thirty-eight studies with 4141 partici-
pants reported the number of failed intubations.23–32 34 36 44 46 48
50 52–55 57–59 62 64–66 69 71 72 74 75 77–79 81–83
We excluded one cross-
over study40 from meta-analysis which introduced too much
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Blinding of participants and personnel (performance bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias)
Selective reporting (reporting bias)
Experience of intubator
Baseline characteristics
Funding sources
Low risk of bias Unclear risk of bias
Fig 2 Risk of bias graph. Review authors’ judgments about each risk of bias item presented as percentages across all included studies.
| 373
performance bias to be equivalent to the others. Analysis dem-
onstrated fewer failed intubations when a videolaryngoscope
was used (OR, random-effects 0.35, 95% CI 0.19 to 0.65; I2¼52%;
n¼4127) (Fig. 3). Evidence from a funnel plot for this outcome
suggested that there was no evidence of reporting bias
(Supplementary Appendix S2).
Hypoxia. Eight studies reported on hypoxia,23 27–29 50 55 71 79 and
only three of these had event data.27–29 Analysis showed no dif-
ference in hypoxia according to type of device (OR, random-
effects 0.39, 95% CI 0.10 to 1.44; I2¼70%; n¼1319) (Supplementary
Appendix S3).
Secondary outcomes
Mortality. Only two studies reported mortality rates. One study38
was based in the ICU and one84 in the emergency department
with no difference in the number of deaths according to type of
device (OR, fixed-effect 1.09, 95% CI 0.65 to 1.82; I2¼29%; n¼663)
(Supplementary Appendix S4).
Serious airway complications. Only one study reported respiratory
complications as an outcome with one recorded event of pneu-
mothorax in the Macintosh group and none in the videolaryngo-
scope group.30
Laryngeal/Airway trauma. Twenty-nine studies reported data for
laryngeal or airway trauma, or both. We performed meta-
analysis of 22 comparisons with event data.21 24 27–30 39 43 44 49 50
53–55 57–59 62 69 78 79 81
The result showed fewer trauma events
when a videolaryngoscope was used (OR, random-effects 0.68,
95% CI 0.48 to 0.96; I2¼25%; n¼3110) (Supplementary Appendix
S5).
Sore throat or hoarseness. Seventeen studies with 2392 partici-
pants reported on sore throat or hoarseness, or both.21 23 24 27 30
43 44 51 55 63–65 69 74 78 79 82
We constructed analysis for studies at
two time points: in the post-anaesthesia care unit (PACU) and at
24 h. Six studies did not state when sore throat was assessed
0% 25% 50% 75% 100%
High risk of bias
 374 | Lewis et al.

Videolaryngoscope Macintosh Odds ratio Odds ratio

Study or subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Andersen 2011 0 50 2 50 2.7% 0.19 (0.01, 4.10)
Aoi 2010 1 18 1 18 2.9% 1.00 (0.06, 17.33)
Arici 2014 0 40 0 40 Not estimable
Arima 2014 2 56 0 53 2.7% 4.91 (0.23, 104.65)
Aziz 2012 6 149 12 147 6.2% 0.47 (0.17, 1.29)
Bensghir 2010 0 34 2 34 2.7% 0.19 (0.01, 4.07)
Bensghir 2013 0 35 1 35 2.5% 0.32 (0.01, 8.23)
Bilehjani 2009 0 40 0 38 Not estimable
Carassiti 2013 0 15 0 15 Not estimable
Cavus 2011 (1) 0 100 6 50 2.9% 0.03 (0.00, 0.62)
Cordovani 2013 3 24 5 20 5.0% 0.43 (0.09, 2.08)
Enomoto 2008 0 99 11 104 2.9% 0.04 (0.00, 0.70)
Ilyas 2014 (2) 5 64 0 64 2.8% 11.92 (0.65, 220.30)
Jungbauer 2009 1 100 8 100 4.0% 0.12 (0.01, 0.95)
Kill 2013 0 30 3 30 2.7% 0.13 (0.01, 2.61)
Komatsu 2010 1 50 0 50 2.5% 3.06 (0.12, 76.95)
Lee 2009 0 41 0 44 Not estimable
Lee 2012 (3) 3 75 1 25 3.7% 1.00 (0.10, 10.07)
Lim 2005 0 30 0 30 Not estimable
Lin 2012 2 85 3 85 4.6% 0.66 (0.11, 4.04)
Malik 2008 (4) 3 90 2 30 4.5% 0.48 (0.08, 3.04)
Malik 2009a 0 30 0 30 Not estimable
Malik 2009b (5) 1 50 4 25 3.8% 0.11 (0.01, 1.02)
McElwain 2011 (6) 1 58 2 31 3.5% 0.25 (0.02, 2.92)
Nishikawa 2009 0 20 0 20 Not estimable
Peck 2009 0 27 13 27 2.9% 0.02 (0.00, 0.35)
Pournajafian 2014 6 52 3 52 5.3% 2.13 (0.50, 9.02)
Russell 2013 6 35 3 35 5.3% 2.21 (0.51, 9.64)
Serocki 2010 (7) 2 80 4 40 4.7% 0.23 (0.04, 1.32)
Serocki 2013 (8) 0 63 4 32 2.8% 0.05 (0.00, 0.96)
Siddiqui 2009 0 20 0 20 Not estimable
Sun 2005 0 100 1 100 2.5% 0.33 (0.01, 8.20)
Takenaka 2011 0 35 5 34 2.8% 0.08 (0.00, 1.42)
Taylor 2013 0 44 18 44 2.9% 0.02 (0.00, 0.28)
Teoh 2010 (9) 0 300 0 100 Not estimable
Walker 2009 1 60 0 60 2.5% 3.05 (0.12, 76.39)
Woo 2012 0 50 59 109 3.0% 0.01 (0.00, 0.14)
Xue 2007 2 30 0 27 2.6% 4.82 (0.22, 105.10)

Total (95% CI) 2279 1848 100.0% 0.35 (0.19, 0.65)

Total events 46 173
2 2 2
Heterogeneity: Tau =1.37; X =57.76, df=28 (P=0.0008); I =52%
0.01 0.1 1 10 100
Test for overall effect: Z=3.33 (P =0.0009)
Favours videolaryngoscope Favours Macintosh
Footnotes
(1) Multi-arm study. Data combined for each videolaryngoscope group
(2) Two failed as a result of equipment failure, three failed due to difficulty passing tube
(3) Multi-arm study. Data combined for each videolaryngoscope group
(4) Multi-arm study. Data combined for each videolaryngoscope group
(5) Multi-arm study. Data combined for each videolaryngoscope group
(6) Multi-arm study. Data combined for each videolaryngoscope group
(7) Multi-arm study. Data combined for each videolaryngoscope group
(8) Multi-arm study. Data combined for each videolaryngoscope group
(9) Multi-arm study. Data combined for each videolaryngoscope group

Fig 3 Comparison: videolaryngoscope (experimental) vs Macintosh (control). Outcome: failed intubation.

and for the purpose of this analysis we included this data in the
PACU group.24 27 30 44 65 69 Analysis showed no difference in inci-
dences of sore throat in PACU (OR, random-effects 1.00, 95% CI
0.73 to 1.38; I2¼24%; n¼1548) or at postoperative day one accord-
ing to type of device (OR, random-effects 0.54, 95% CI 0.27 to
1.07; I2¼74%; n¼844) (Supplementary Appendix S6).
Six studies reported data for hoarseness. We combined data
regardless of time of measurement. There were fewer inciden-
ces of hoarseness for those with whom a videolaryngoscope
had been used (OR, fixed-effect 0.57, 95% CI 0.36 to 0.88; I2¼28%;
n¼527) (Supplementary Appendix S7).
Proportion of successful first attempts. We combined data from 36
studies for successful first attempt.21 23–28 30 32 37–39 42 43 49 50 53–55
57–59 62 69 71–73 75–79 81–84
Analysis showed no difference in the
number of successful first attempts according to type of device
(OR, random-effects 1.27, 95% CI 0.77 to 2.09; I2¼79%; n¼4731)
(Supplementary Appendix S8).
Number of attempts. Thirty studies reported number of attempts
as an outcome and we were able to combine data for 28 stud-
ies.21 23 24 28 30 32 37–39 42 43 49 50 53–55 57–59 62 71–73 75 79 81–83 Analysis
showed no difference between type of device for those
 Videolaryngoscopy versus direct laryngoscopy for adult patients
participants intubated in one attempt (OR, random-effects 1.25,
95% CI 0.68 to 2.31; I2¼79%; n¼3346). We combined the data
from studies reporting two, three or four attempts, and there
was no difference between type of laryngoscope with additional
attempts (OR, random-effects 0.89, 95% CI 0.47 to 1.70; I2¼79%;
n¼3346) (Supplementary Appendix S9).
Time for tracheal intubation. Fifty-five studies reported time for
tracheal intubation. Of these, 18 were excluded from formal
analysis because of unit of analysis issues. The remaining
37 studies included multi-arm studies with a total of 44 compar-
isons.24 25 27–33 35 36 42–44 47 49–51 54 58 61 63–66 70 72–76 78–80 82–84 We
identified an extremely high level of statistical heterogeneity
(I2¼96%) when these 37 studies were combined, possibly
explained by the various time points at which individual studies
measured this outcome. Therefore, we have not presented an
effects estimate for time for intubation (Supplementary
Appendix S10).
Difficulty of intubation. Nineteen studies with 1765 participants
reported difficulty of tracheal intubation.21 23 24 26 29 33 37 39 44 45
54–59 62 70 77
Fourteen used the same validated scale of measure-
ment (Intubation Difficulty Score (IDS) 23 24 26 28 37 39 44 55 57–59 62 70
77
of which we were able to combine seven studies.24 29 39 57–59 62
Analysis demonstrated that a videolaryngoscope was easier to
use when compared with the Macintosh, with 165 of 340 cases
being given the lowest IDS score of 0 in the videolaryngoscope
group, vs 31 of 228 cases in the Macintosh group (OR, random-
effects 7.13, 95% CI 3.12 to 16.31; I2¼62%; n¼568). Of the remain-
ing studies that used an IDS scoring system, four reported a
statistically significant result in favour of the videolaryngoscope.
Five studies used alternative scales to IDS, with differences in
direction of effect reported between studies.21 33 45 54 69
(Supplementary Appendix S11).
Improved visualisation. Thirty six studies assessed visualisation
using the Cormack and Lehane (CL)12 scoring system and we
were able to perform meta-analysis in 22 studies.23–25 27–29 37–39
49 50 53–55 57–59 61 62 77 79 81
This showed a higher number of lar-
yngoscopies achieving a grade 1 CL view (i.e. more than 50% of
the cords were visible) when a videolaryngoscope was used (OR,
random-effects 6.77, 95% CI 4.17 to 10.98; I2¼74%; n¼2240). We
combined data for CL grades 1 to 2 and for grades 3 to 4. This
also showed more laryngoscopies achieving a CL grade 1 or 2
with a videolaryngoscope (OR, random-effects 5.42, 95% CI 3.70
to 7.95; I2¼5%; n¼2240), and fewer videolaryngoscope laryngos-
copies achieving a CL grade 3 or 4 (OR, random-effects 0.18, 95%
CI .013 to 0.27; I2¼5%; n¼2240). There were five studies that used
the POGO (percentage of glottic opening) scoring method.33 40 65
70 82
Combined results demonstrated extremely high heteroge-
neity (I2¼96%) and data were therefore not pooled (Supplement-
ary Appendix S12–S14).
Additional analyses
Subgroup analysis
Videolaryngoscope design
Of four videolaryngoscope designs with enough data for
meta-analysis, three (GlideScope, Pentax or McGrath Series 5)
demonstrated no differences in the number of failed intuba-
tions compared with the Macintosh blade (GlideScope: OR,
random-effects 0.57, 95% CI 0.25 to 1.32; I2¼24%; n¼1306, Pentax:
OR, random-effects 0.24, 95% CI 0.05 to 1.20; I2¼59% n¼1086,
| 375
McGrath Series 5 OR, random-effects 1.18, 95% CI 0.06 to 23.92;
I2¼78%; n¼466) while with the CMAC Macintosh blade there was
a reduction in failed tracheal intubation (OR, random-effects
0.32, 95% CI 0.15 to 0.68; I2¼0%; n¼1058) (Fig. 4).
Anticipated or known difficult intubations
There were fewer intubation failures when a videolaryngoscope
was used with participants who had a predicted difficult airway
(OR, random-effects 0.28, 95% CI 0.15 to 0.55; I2¼0%; n¼830) or a
simulated difficult airway (OR, random-effects 0.18, 95% CI 0.04
to 0.77; I2¼53%; n¼810). There was no difference in failed intuba-
tion by type of device for participants with no predicted difficult
airway (OR, random-effects 0.61, 95% CI 0.22 to 1.67; I2¼56%;
n¼1743) (Fig. 5).
Experience of intubator
We compared studies that included experienced personnel (i.e.
20 patient intubations with each device) with studies that
used intubators who were inexperienced with the videolaryngo-
scope (<20 intubations; or unfamiliar with using double-lumen
tubes for intubation). Studies with personnel experienced in
both devices had fewer failed intubations when a videolaryngo-
scope was used (OR, random-effects 0.32, 95% CI 0.13 to 0.75;
I2¼47%; n¼1927), but there was no evidence of a difference in
failed intubations when personnel were inexperienced with a
videolaryngoscope (OR, random-effects 0.20, 95% CI 0.02 to 2.56;
I2¼75%; n¼346) (Supplementary Appendix S15).
Obese and non-obese participants
We identified two studies21 23 that included obese participants.
Only one study23 included data for our primary outcomes and
therefore it was not feasible to perform subgroup analysis
against studies with non-obese participants.
Different sites of intubation
We identified three studies26 38 84 that were in the emergency or
prehospital setting. Only one study26 included data for our pri-
mary outcomes and therefore it was not feasible to perform sub-
group analysis against studies in the elective setting.
Sensitivity analysis
To investigate the robustness of the evidence, we conducted
four separate sensitivity analyses: missing data, cross-over
studies, multi-arm studies, and risk of bias.
• We removed studies for which we had been unable to judge
whether data were complete and studies that had a partici-
pant loss of more than 10% or participant loss was unex-
plained.15 Interpretation of effect estimates remained
unchanged for all outcomes except for sore throat on postop-
erative day 1, for which the removal of one study82 revealed
fewer sore throats when a videolaryngoscope was used (OR,
random-effects 0.45, 95% CI 0.22 to 0.90).
• After the removal of cross-over studies, there was no differ-
ence in the results for all outcomes except laryngeal/airway
trauma which was no longer statistically significant (OR,
random-effects 0.75, 95% CI 0.51 to 1.11).
• This review included a number of multi-arm studies that
compared more than one videolaryngoscope against a
Macintosh. We avoided unit of analysis errors in our primary
analysis by selecting outcome data in the multi-arm studies
for the videolaryngoscope design which had the lowest event
rates. We used sensitivity analysis to assess the effect of this
 376 | Lewis et al.

Videolaryngoscope Macintosh Odds ratio Odds ratio

Study or subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
15.1.1 GlideScope
Andersen 2011 0 50 2 50 2.8% 0.19 (0.01, 4.10)
Bilehjani 2009 0 40 0 38 Not estimable
Carassiti 2013 0 15 0 15 Not estimable
Kill 2013 0 30 3 30 2.9% 0.13 (0.01, 2.61)
Lee 2012 0 25 1 25 2.6% 0.32 (0.01, 8.25)
Lim 2005 0 30 0 30 Not estimable
Malik 2008 0 30 2 30 2.8% 0.19 (0.01, 4.06)
Malik 2009b 1 25 4 25 4.0% 0.22 (0.02, 2.11)
Pournajafian 2014 6 52 3 52 5.8% 2.13 (0.50, 9.02)
Russell 2013 6 35 3 35 5.7% 2.21 (0.51, 9.64)
Serocki 2010 1 40 4 40 4.0% 0.23 (0.02, 2.16)
Serocki 2013 0 35 4 32 2.9% 0.09 (0.00, 1.73)
Siddiqui 2009 0 20 0 20 Not estimable
Sun 2005 0 100 1 100 2.6% 0.33 (0.01, 8.20)
Teoh 2010 0 100 0 100 Not estimable
Xue 2007 2 30 0 27 2.8% 4.82 (0.22, 105.10)
Subtotal (95% CI) 657 649 38.8% 0.57 (0.25, 1.32)
Total events 16 27
2 2 2
Heterogeneity: Tau =0.45; X =13.09, df=10 (P=0.22); I = 24%
Test for overall effect: Z=1.31 (P =0.19)

15.1.2 Pentax AWS

Aoi 2010 1 18 1 18 3.1% 1.00 (0.06, 17.33)
Arima 2014 2 56 0 53 2.8% 4.91 (0.23, 104.65)
Enomoto 2008 0 99 11 104 3.1% 0.04 (0.00, 0.70)
Komatsu 2010 1 50 0 50 2.6% 3.06 (0.12, 76.95)
Malik 2008 1 30 2 30 3.7% 0.48 (0.04, 5.63)
Malik 2009a 0 30 0 30 Not estimable
Malik 2009b 0 25 4 25 2.9% 0.09 (0.00, 1.84)
Nishikawa 2009 0 20 0 20 Not estimable
Takenaka 2011 0 35 5 34 3.0% 0.08 (0.00, 1.42)
Teoh 2010 0 100 0 100 Not estimable
Woo 2012 0 50 59 109 3.1% 0.01 (0.00, 0.14)
Subtotal (95% CI) 513 573 24.2% 0.24 (0.05, 1.20)
Total events 5 82
Heterogeneity: Tau2 =3.10; X2 =17.06, df=7 (P=0.02); I2 = 59%
Test for overall effect: Z=1.74 (P =0.08)

15.1.3 McGrath
Arici 2014 0 40 0 40 Not estimable
lIyas 2014 (1) 5 64 0 64 3.0% 11.92 (0.65, 220.30)
Lee 2012 3 25 1 25 3.9% 3.27 (0.32, 33.84)
Taylor 2013 0 44 18 44 3.1% 0.02 (0.00, 0.28)
Walker 2009 1 60 0 60 2.6% 3.05 (0.12, 76.39)
Subtotal (95% CI) 233 233 12.5% 1.18 (0.06, 23.92)
Total events 9 19
Heterogeneity: Tau2 =7.36; X2 =13.80, df=3 (P=0.003); I2 = 78%
Test for overall effect: Z=0.11 (P =0.92)

15.1.4 C-MAC
Aziz 2012 6 149 12 147 6.8% 0.47 (0.17, 1.29)
Cavus 2011 0 37 6 50 3.0% 0.09 (0.00, 1.67)
Jungbauer 2009 1 100 8 100 4.3% 0.12 (0.01, 0.95)
Lee 2009 0 41 0 44 Not estimable
Lee 2012 0 25 1 25 2.6% 0.32 (0.01, 8.25)
McElwain 2011 1 29 2 31 3.7% 0.52 (0.04, 6.04)
Serocki 2010 1 40 4 40 4.0% 0.23 (0.02, 2.16)
Teoh 2010 0 100 0 100 Not estimable
Subtotal (95% CI) 521 537 24.4% 0.32 (0.15, 0.68)
Total events 9 33
2 2 2
Heterogeneity: Tau =0.00; X =2.51, df=5 (P=0.77); I =0%
Test for overall effect: Z=2.96 (P =0.003)

Total (95% CI) 1924 1992 100.0% 0.40 (0.21, 0.75)

Total events 39 161
Heterogeneity: Tau2 =1.26; X2 =52.10, df=28 (P=0.004); I2 =46%
0.01 0.1 1 10 100
Test for overall effect: Z=2.86 (P =0.004) Favours videolaryngoscope Favours Macintosh
2 2
Test for subgroup differences: X =1.87, df=3 (P=0.60); I =0%
Footnotes
(1) Two failed as a result of equipment failure, three failed as a result of difficulty passing tube

Fig 4 Subgroup analysis. Comparison: videolaryngoscope vs Macintosh. Outcome: failed intubation by scope.
 Videolaryngoscopy versus direct laryngoscopy for adult patients | 377

Videolaryngoscope Macintosh Odds ratio Odds ratio

Study or subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
16.1.1 Predicted not difficult
Andersen 2011 0 50 2 50 2.8% 0.19 (0.01, 4.10)
Arici 2014 0 40 0 40 Not estimable
Bensghir 2010 0 34 2 34 2.8% 0.19 (0.01, 4.07)
Bensghir 2013 0 35 1 35 2.6% 0.32 (0.01, 8.23)
Bilehjani 2009 0 40 0 38 Not estimable
Carassiti 2013 0 15 0 15 Not estimable
lIyas 2014 (1) 5 64 0 64 3.0% 11.92 (0.65, 220.30)
Kill 2013 0 30 3 30 2.9% 0.13 (0.01, 2.61)
Lee 2012 (2) 3 75 1 25 3.9% 1.00 (0.10, 10.07)
Lin 2012 2 85 3 85 4.9% 0.66 (0.11, 4.04)
Nishikawa 2009 0 20 0 20 Not estimable
Pournajafian 2014 6 52 3 52 5.7% 2.13 (0.50, 9.02)
Russell 2013 6 35 3 35 5.7% 2.21 (0.51, 9.64)
Siddiqui 2009 0 20 0 20 Not estimable
Sun 2005 0 100 1 100 2.6% 0.33 (0.01, 8.20)
Takenaka 2011 0 35 5 34 3.0% 0.08 (0.00, 1.42)
Walker 2009 1 60 0 60 2.6% 3.05 (0.12, 76.39)
Woo 2012 0 50 59 109 3.1% 0.01 (0.00, 0.14)
Xue 2007 2 30 0 27 2.8% 4.82 (0.22, 105.10)
Subtotal (95% Cl) 870 873 48.2% 0.61 (0.22, 1.67)
Total events 25 83
Heterogeneity: Tau2 =1.93; X2 =29.56, df=13 (P=0.005); I2 = 56%
Test for overall effect: Z=0.96 (P =0.34)

16.1.2 Predicted difficult

Aziz 2012 6 149 12 147 6.8% 0.47 (0.17, 1.29)
Cordovani 2013 3 24 5 20 5.4% 0.43 (0.09, 2.08)
Jungbauer 2009 1 100 8 100 4.3% 0.12 (0.01, 0.95)
Malik 2009b (3) 1 50 4 25 4.0% 0.11 (0.01, 1.02)
Serocki 2010 (4) 2 80 4 40 5.0% 0.23 (0.04, 1.32)
Serocki 2013 (5) 0 63 4 32 2.9% 0.05 (0.00, 0.96)
Subtotal (95% Cl) 466 364 28.4% 0.28 (0.15, 0.55)
Total events 13 37
2 2 2
Heterogeneity: Tau =0.00; X =4.12, df=5 (P=0.53); I =0%
Test for overall effect: Z=3.70 (P =0.0002)

16.1.3 Simulated difficult

Aoi 2010 1 18 1 18 3.1% 1.00 (0.06, 17.33)
Enomoto 2008 0 99 11 104 3.1% 0.04 (0.00, 0.70)
Komatsu 2010 1 50 0 50 2.6% 3.06 (0.12, 76.95)
Lim 2005 0 30 0 30 Not estimable
Malik 2008 (6) 3 90 2 30 4.8% 0.48 (0.08, 3.04)
Malik 2009a 0 30 0 30 Not estimable
McElwain 2011 (7) 1 58 2 31 3.7% 0.25 (0.02, 2.92)
Peck 2009 0 27 13 27 3.0% 0.02 (0.00, 0.35)
Taylor 2013 0 44 18 44 3.1% 0.02 (0.00, 0.28)
Subtotal (95% Cl) 446 364 23.3% 0.18 (0.04, 0.77)
Total events 6 47
Heterogeneity: Tau2 =2.05; X2 =12.88, df=6 (P=0.04); I2 = 53%
Test for overall effect: Z=2.31 (P =0.02)

Total (95% Cl) 1782 1601 100.0% 0.35 (0.18, 0.65)

Total events 44 167
Heterogeneity: Tau2 =1.27; X2 =52.44, df=26 (P=0.002); I2 =50%
0.01 0.1 1 10 100
Test for overall effect: Z=3.29 (P =0.0010)
2 2 Favours videolaryngoscope Favours Macintosh
Test for subgroup differences: X =2.29; df=2 (P=0.32); I = 12.5%
Footnotes
(1) Two failed as a result of equipment failure, three failed as a result of difficulty passing tube
(2) Multi-arm study. Data combined for each videolaryngoscope group
(3) Multi-arm study. Data combined for each videolaryngoscope group
(4) Multi-arm study. Data combined for each videolaryngoscope group
(5) Multi-arm study. Data combined for each videolaryngoscope group
(6) Multi-arm study. Data combined for each videolaryngoscope group
(7) Multi-arm study. Data combined for each videolaryngoscope group

Fig 5 Subgroup analysis. Comparison: videolaryngoscope vs Macintosh. Outcome: failed intubation by airway difficulty.
 378 | Lewis et al.
decision by selecting outcome data for the videolaryngoscope
design which had the highest event rates. The effect esti-
mates remained unchanged for all outcomes except laryng-
eal/airway trauma which was no longer statistically
significant (OR, random-effects 0.73, 95% CI 0.52 to 1.03).
• We considered the impact of our risk of bias assessments on
our primary outcome of failed intubation. Removing studies
which had an unclear or high risk of selection bias did not sig-
nificantly affect the results (M-H OR, fixed-effect 0.41, 95% CI
0.26 to 0.63; 23 studies; 2811 participants). Similarly, removing
studies which had a high risk of attrition bias resulted in no
significant change in the effect estimate (M-H OR, fixed-effect
0.36, 95% CI 0.26 to 0.51; 34 studies; n ¼ 3624).
Discussion
Summary of main results
We found 64 studies comparing videolaryngoscopy with direct
laryngoscopy in patients requiring tracheal intubation for gen-
eral anaesthesia. Analysis of 38 studies, including all types of
videolaryngoscope, demonstrated statistically significantly
fewer failed intubations when a videolaryngoscope was used.
However, when analysis was carried out by type of videolar-
yngoscope, only the CMAC Macintosh blade showed a statisti-
cally significant decrease in failed intubations while for the
GlideScope, Pentax or McGrath Series 5 we found no statistically
significant difference. Failed intubations were significantly
fewer when a videolaryngoscope was used in participants with
an anticipated difficult airway (in most cases defined by a
Mallampati score of 3 or 4) or a simulated difficult airway, whilst
there was no difference in failed intubations in participants
who presented without an anticipated difficult airway. (In this
respect, we would note that there is significant risk of type 2
error in ‘predicted easy’ as failed intubation is infrequent and
some studies include all patients at any elevated risk above
‘normal’). We also found that there were fewer failed intuba-
tions using a videolaryngoscope when the intubator had equiva-
lent experience with both devices, but not when the intubator
was experienced with the Macintosh but not the
videolaryngoscope.
Analysis of the other outcomes demonstrated statistically
significantly fewer laryngeal/airway traumas and fewer inciden-
ces of postoperative hoarseness when a videolaryngoscope was
used. However, as in all systematic reviews, the findings follow
partly from the decisions made during the review process.108
Here, the result for laryngeal/airway trauma was dependent on
our decision to include cross-over designs and which data to
use for included multi-arm studies. When using a videolaryngo-
scope, compared with Macintosh laryngoscopy there was statis-
tically significantly higher number of laryngoscopies achieving
a Cormack and Lehane grade 1 view, and a grade 1-2 view and
fewer achieving a grade 3-4 view. The videolaryngoscope was
easier to use than the Macintosh. Conversely, one could argue
that the degree of heterogeneity (whether it arose from issues
with definitions of outcomes, study protocols etc.) within the
studies detailed in Figure 3 was too high to perform a meta-
analysis at all. We opted to do so, but have drawn attention to
the generally low quality of evidence throughout the presenta-
tion of this review.
There were only three studies reporting results that we were
able to combine for hypoxia. For this outcome, there was no dif-
ference between type of device used. Similarly, there were few
studies reporting on mortality and respiratory complications.
The fact that most studies were performed in the elective set-
ting where all these complications are uncommon or rare may
influence these findings. There was no statistically significant
difference in the incidence of sore throat either in PACU or at
24 h postoperatively. There was no statistically significant dif-
ference between devices in the proportion of successful first
attempts, nor at those needing more than one attempt. There
was a very high level of heterogeneity when studies that
reported time for tracheal intubation were combined, possibly
explained by the various time points used to measure this out-
come and as a result, we did not present an effects estimate for
this outcome.
It was not possible to blind personnel to the type of laryngo-
scope used; we believed that all studies were subject to a high
level of performance bias owing to the potential for user prefer-
ence. However, we considered other types of bias in our sensi-
tivity analysis, and despite varied levels of bias across studies,
results for our primary outcome of failed intubation were not
affected by the quality of the evidence when combined in meta-
analysis. When using GRADE to assess quality across the
included studies, we believed that the unavoidable high level of
performance bias in all studies should take preference when the
risk of bias for this review was summarized (Supplementary
Appendix S16). As a result, we downgraded evidence for each of
our outcomes by one level for study limitations. We assessed
the outcomes failed intubation, proportion of successful first
attempts, and sore throat, to be moderate quality evidence. We
included few studies that reported hypoxia, serious respiratory
complications, or mortality, which introduced imprecision; we
downgraded these outcomes to very low quality evidence.
There were a large number of studies with substantial heteroge-
neity that reported time for tracheal intubation and we down-
graded the evidence for this outcome to very low quality. Our
findings are consistent with recent reviews109–111 which indicate
that this improvement is more pronounced in patients with a
difficult airway,109 and which recommend the use of videolar-
yngoscopes to achieve successful intubation in patients with a
higher risk of difficult laryngoscopy.112 Whether the evidence is
sufficient to support videolaryngoscopy for all intubations will
remain a matter for debate.113
Limitations
We excluded studies that had used particular devices (such as
the Airtraq and Truview EVO2 laryngoscopes) and had not
described in the study report whether these were used with a
video/camera attachment; as we only intended to include stud-
ies where a screen (indirect view) had been used, we therefore
excluded 38 such studies from the review. We encountered diffi-
culty establishing the actual level of experience of personnel,
either by the number of yr of relevant experience or by the num-
ber of experiences using each device; although we attempted to
measure the review outcomes by level of experience, our results
are only applicable according to our own interpretation of this.
If future studies were to be performed with universally agreed
outcomes and definitions of those outcomes, the ‘ease of use’
and value of the studies themselves and of future meta-analy-
ses would be improved.
The use of videolaryngoscopes in particular clinical scenar-
ios has not been sufficiently explored in this review, for exam-
ple in the emergency setting during anaesthesia, and in the ICU,
emergency department and outside hospitals. Also, we were
not able to usefully distinguish performance differences
 Videolaryngoscopy versus direct laryngoscopy for adult patients
between different videolaryngoscopes, but it is unlikely that
devices of such differing designs all perform equally. We re-ran
the search in January 2016, before publication of the Cochrane
version of this review, and are aware of additional published
studies that have not been included here and ongoing studies
identified in clinical trial register searches. This demonstrates
continued research interest in this field, and incorporation of
data from these studies, during a formal Cochrane update, may
lead to changes in the results of this review.
Implications for research
Although there are a substantial number of studies in this sys-
tematic review, thus avoiding some of the difficulties of reviews
with sparse data,114 its conclusions must be limited by the vari-
ability in definitions used (for instance, for failed intubation),
settings and devices. This has given rise to considerable hetero-
geneity and, taken together with the limited methodological
quality of some of the studies, means that the results must be
interpreted with caution. It is clear that future airway research
should use standardised outcomes and procedures. Within peri-
operative care research, a recent attempt has been made to
standardise definitions115 and we would welcome a similar
attempt in airway research. A forthcoming editorial in the
Journal will also touch on this.116 There is also a notable lack of
studies in high-risk patients (those who are generally difficult to
intubate, rather than rendered so by repositioning, the applica-
tion of cervical collars etc.)117 and patients in different (high-
risk) settings such as the emergency department or ICU. Further
studies directly comparing videolaryngoscopes of different
types would also be welcome.
Conclusions and implications for practice
Our evidence suggests that videolaryngoscopes reduce intuba-
tion failure and make intubation easier, particularly in patients
with a predicted or known difficult airway. Their use is likely to
improve the glottic view and reduce the number of laryngoscop-
ies in which the glottis cannot be seen, irrespective of predicted
or known difficulty, and may reduce the incidence of laryngeal/
airway trauma. We found no evidence to indicate that the use of
a videolaryngoscope would result in fewer attempts to intubate.
We were not able to establish whether intubation is likely to
take less or more time with a videolaryngoscope, nor whether
this would result in fewer incidences of hypoxia or respiratory
complications.
Authors’ contributions
Study design: A.S., S.L., T.C.
Study conduct: A.S., S.L., T.C., J.P., A.B.
Data analysis: S.L., A.S., T.C.
Writing paper: S.L., A.S., T.C., O.S-R.
Revising paper: all authors
Supplementary material
Supplementary material is available at British Journal of
Anaesthesia online.
Acknowledgements
We would like to thank the Cochrane Review group -
Anaesthesia, Critical and Emergency Care (ACE) – for their
| 379
support in publishing the Cochrane review. In particular, we
would like to thank Jane Cracknell (Managing Editor),
Rodrigo Cavallazzi (Content Editor), Cathal Walsh and
Marialena Trivella (Statistical Editors), Davide Cattano,
Joshua Atkins, Shirley Zhao and Melissa Rethlefsen (peer
reviewers) and Odi Geiger (Consumer Referee), for their help
and editorial advice during the preparation of the protocol
and review. We would also like to thank Amanda Nicholson
who was an author of the protocol.14
We would like to thank those authors that responded to
requests for further study information, particularly Dr
Waleed Riad, Dr Daniel Cordovani and Dr Aki Suzuki.
Declaration of interest
One review author (T.C.) was paid for lecturing, several yr
ago (>36 months), by Intavent Orthofix and the LMA
Company. This company manufactures and distributes sev-
eral supraglottic airway devices and one videolaryngoscope:
AP Venner. T.C.’s department has received free or at cost air-
way equipment from numerous ‘airway’ companies for
evaluation or research. He and his family have no financial
investments and no ownership of any such company of
which he is aware. He spoke at a Storz educational meeting
in 2015, and the company paid the costs of travel to this
meeting and accommodations. He received no financial ben-
efit from the meeting and was not paid to speak. T.C. has no
other known conflicts of interest. All remaining authors
have no known conflicts of interest in this review.
Funding
This work was supported by the National Institute for
Health Research: Cochrane Collaboration Programme Grant:
Enhancing the safety, quality and productivity of periopera-
tive care (grant number 10/4001/04). This grant funded the
work of S.R.L, A.B., A.F.S. and P.A. for this review.
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Handling editor: Jonathan Hardman