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Original Investigation
Caring for the Critically Ill Patient
February 7, 2017

Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU PatientsA Randomized Clinical Trial

Author Affiliations
  • 1Medical-Surgical Intensive Care Unit, District Hospital Centre, La Roche-sur-Yon, France
  • 2Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
  • 3EA 7293, Fédération de Médecine Translationnelle de Strasbourg, Faculté de Médecine, Université de Strasbourg, Strasbourg, France
  • 4Clinical Research Unit, District Hospital Centre, La Roche-sur-Yon, France
  • 5Delegation a la Recherche Clinique et a l’Innovation-CHU Hotel Dieu, Nantes, France
  • 6Medical Intensive Care Unit, Regional Hospital Centre, Orleans, France
  • 7Medical Intensive Care Unit, University Hospital Centre, Tours, France
  • 8AP-HP, Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, F-92700, Colombes, France
  • 9INSERM, IAME 1137, Sorbonne Paris Cité, F-75018, Paris, France
  • 10APHP Hôpital Saint Louis, Service de Réanimation Médicale, Paris, France
  • 11Medical Intensive Care Unit, Cochin University Hospital Centre, Paris, France
  • 12Medical Intensive Care Unit, University Hospital Centre, Nantes, France
  • 13EA 3826, Clinical and Experimental Treatments for Infections, University of Medicine, Nantes, France
JAMA. 2017;317(5):483-493. doi:10.1001/jama.2016.20603
Key Points

Question  Should video laryngoscopy be used for orotracheal intubation in the intensive care unit (ICU) despite conflicting evidence that it improves the first-pass success rate?

Findings  Video laryngoscopy for orotracheal intubation in the ICU did not improve the first-pass success rate compared with conventional direct laryngoscopy (67.7% vs 70.3%, respectively).

Meaning  Video laryngoscopy did not improve the frequency of successful first-pass intubation in the ICU.


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 laryngoscopy may 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 intubation was 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 laryngoscopy was 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 laryngoscopy was 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.

Trial Registration  clinicaltrials.gov Identifier: NCT02413723