Videolaryngoscopy in the Critically Ill

Hypothesis: In this study, we hypothesize that videolaryngoscopy (VL) is associated with a decreased risk of intubation failure compared to direct laryngoscopy in the critically ill. We also hypothesize that VL is associated with fewer number of intubation attempts and decreased risk of complications compared to DL.

Background: In the critically ill, endotracheal intubation is a high-risk procedure with complications occurring in up to 54% of patients. Our own published work has demonstrated that more than one attempt at intubation occurred in 33% of patients and was associated with a three-fold increased risk of severe complications. VL provides a superior laryngeal view when compared to DL which may translate into less failed intubations, and resultant decreased complications.

Specific objectives:

• Determine point estimates for failure to intubate on the first attempt, which can then be used to power a larger efficacy trial examining VL vs. DL in the critically ill.
• Compare VL vs. DL on risk of intubation failure (as defined by one than more attempt)
• Compare VL vs. DL on number of attempts at endotracheal intubation, time-to-intubate, and risk of complications.

Methods:

• Design: Single center, randomized-controlled pilot study
• Patients: Forty critically ill patients requiring urgent endotracheal intubation (within 30 minutes) by the intensive care team.
• Intervention: Patients will be randomized to initial attempt at intubation by VL vs DL.
• Power Calculation: Given this is a pilot study to generate point estimates, power calculations have not been performed. However, 20 patients in each arm will provide a robust point estimate that can be used to power a future efficacy study.
• Analysis: Data will be analyzed in an intention-to-treat fashion. Our primary objective, failure to intubate on the first attempt, will be analyzed using Fisher's exact test. This test will also be used to analyze the risk of complications comparing VL to DL. Number of attempts at intubation and time-to-intubation will be analyzed using a Wilcoxon rank-sum test.
• Potential Pitfalls: As slow recruitment is always a concern, we conservatively estimate that 5 patients will be enrolled per month, thus requiring a total of 8 months for patient accrual.

Significance: If VL results in fewer complications during endotracheal intubation, then this technique may become widely adopted for this high risk procedure. Furthermore, in many centers, anesthesiology support for airway management of the critically ill may be limited, if at all present. Thus, the impact of this research may be even more applicable outside of the tertiary teaching centers where airway management expertise is readily available.

Inclusion criteria

• Any patient over the age of 16 years, requiring urgent (within 30 minutes) endotracheal intubation, who are attended to by the critical care team will be eligible for enrolment

Exclusion criteria

• Patients who require intubation within 5 minutes or have contraindications to either of the study intubation technique will be ineligible
• cardiac arrest
• cardiopulmonary instability (oxygen saturation <90% or systolic blood pressure < 80 mmHg despite oxygen or fluid therapy)
• any clinical deterioration while awaiting randomization
• known prior or anticipated difficult intubation
• need for awake intubation (defined by sedation, topicalization and avoidance of neuromuscular blockade)
• pregnancy
• cervical spine precautions
• any patient deemed inappropriate for enrolment by the attending physician