Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients A Randomized Clinical Trial
Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients A Randomized Clinical Trial
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DOI：
10.1001/jama.2016.20603
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发表时间：
2017-02-07
影响因子：
120.7
通讯作者：
Reignier, Jean
中科院分区：
文献类型：
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作者：
Lascarrou, Jean Baptiste;Boisrame-Helms, Julie;Reignier, Jean
由于气管插管在重症监护病房(ICU)中的重要性，经口气管插管可能会增加并发症的风险，因为患者可能非常不稳定，需要立即进行干预，通常是由具有非专家技能的医生进行。目的确定在ICU患者中，与直接喉镜相比，视频喉镜是否增加了第一次成功经口气管插管的频率。设计、设置和参与者随机对2015年5月至2016年1月在法国7个ICU接受治疗时需要插管的371名成年人进行临床试验；随访28天。干预使用视频喉镜(n=186)或直接喉镜(n=185)。所有患者都接受了全身麻醉。主要结果和测量主要结果是首次插管成功的患者的比例。结果371名随机患者(平均年龄62.8[15.8]岁；136名女性[36.7%])完成试验。视频喉镜组和直接喉镜组首次插管成功率差异无统计学意义(67.7%比70.3%；绝对差异-2.5%[95%CI，-11.9%比6.9%]；P=0.60)。非专家(主要是住院医生，n=290)进行首次插管的比例在两组之间没有差异(视频喉镜为84.4%，直接喉镜为83.2%；绝对差异1.2%[95%CI，-6.3%至8.6%]；P=0.76)。视频喉镜和直接喉镜插管成功的中位时间均为3分钟(范围2~4分钟)(绝对差异，0[95%可信区间0~0]；P=0.95)。电视喉镜检查与危及生命的并发症无关(直接喉镜检查：24/180[13.3%]vs 17/179[9.5%]；绝对差异3.8%[95%CI，-2.7%~10.4%]；P=0.25)。在事后分析中，直接喉镜检查与严重威胁生命的并发症(17/179[9.5%]vs 5/179[2.8%]；绝对差异，6.7%[95%CI，1.8%至11.6%]；P=.01)有关，但与轻至中度威胁生命的并发症(10/181[5.4%]vs 14/181[7.7%]；绝对差异，-2.3%[95%CI，-7.4%至2.8%]；结论在需要插管的ICU患者中，视频喉镜与直接喉镜相比并不能提高第一次经口气管插管率，而且与严重威胁生命的并发症的发生率较高相关。还需要进一步的研究来评估这两种策略在不同临床环境和不同技能水平的操作员之间的比较有效性。
IMPORTANCE In the intensive care unit (ICU), orotracheal intubation can be associated with increased risk of complications because the patient may be acutely unstable, requiring prompt intervention, often by a practitioner with nonexpert skills. Video laryngoscopymay decrease this risk by improving glottis visualization.OBJECTIVE To determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients.DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between May 2015 and January 2016; there was 28 days of follow-up.INTERVENTIONS Intubation using a video laryngoscope (n = 186) or direct laryngoscopy (n = 185). All patients received general anesthesia.MAIN OUTCOMES AND MEASURES The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications.RESULTS Among 371 randomized patients (mean [SD] age, 62.8 [15.8] years; 136 [36.7%] women), 371 completed the trial. The proportion of patients with successful first-pass intubation did not differ significantly between the video laryngoscopy and direct laryngoscopy groups (67.7% vs 70.3%; absolute difference, -2.5%[95% CI, -11.9% to 6.9%]; P=.60). The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with video laryngoscopy vs 83.2% with direct laryngoscopy; absolute difference 1.2%[95% CI, -6.3% to 8.6%]; P=.76). The median time to successful intubationwas 3 minutes (range, 2 to 4 minutes) for both video laryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; P=.95). Video laryngoscopywas not associated with life-threatening complications (24/180 [13.3%] vs 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, -2.7% to 10.4%]; P=.25). In post hoc analysis, video laryngoscopywas associated with severe life-threatening complications (17/179 [9.5%] vs 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7%[95% CI, 1.8% to 11.6%]; P=.01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs 14/181 [7.7%]; absolute difference, -2.3%[95% CI, -7.4% to 2.8%]; P=.37).CONCLUSIONS AND RELEVANCE Among patients in the ICU requiring intubation, video laryngoscopy compared with direct laryngoscopy did not improve first-pass orotracheal intubation rates and was associated with higher rates of severe life-threatening complications. Further studies are needed to assess the comparative effectiveness of these 2 strategies in different clinical settings and among operators with diverse skill levels.