Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis

Donald E G Griesdale, David Liu, James McKinney, Peter T Choi, Donald E G Griesdale, David Liu, James McKinney, Peter T Choi

Abstract

Introduction: The Glidescope(®) video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation.

Methods: We systematically searched electronic databases, conference abstracts, and article references. We included trials in humans comparing Glidescope(®) video-laryngoscopy to direct laryngoscopy regarding the glottic view, successful first-attempt intubation, and time to intubation. We generated pooled risk ratios or weighted mean differences across studies. Meta-regression was used to explore heterogeneity based on operator expertise and intubation difficulty.

Results: We included 17 trials with a total of 1,998 patients. The pooled relative risk (RR) of grade 1 laryngoscopy (vs ≥ grade 2) for the Glidescope(®) was 2.0 [95% confidence interval (CI) 1.5 to 2.5]. Significant heterogeneity was partially explained by intubation difficulty using meta-regression analysis (P = 0.003). The pooled RR for nondifficult intubations of grade 1 laryngoscopy (vs ≥ grade 2) was 1.5 (95% CI 1.2 to 1.9), and for difficult intubations it was 3.5 (95% CI 2.3 to 5.5). There was no difference between the Glidescope(®) and the direct laryngoscope regarding successful first-attempt intubation or time to intubation, although there was significant heterogeneity in both of these outcomes. In the two studies examining nonexperts, successful first-attempt intubation (RR 1.8, 95% CI 1.4 to 2.4) and time to intubation (weighted mean difference -43 sec, 95% CI -72 to -14 sec) were improved using the Glidescope(®). These benefits were not seen with experts.

Conclusion: Compared to direct laryngoscopy, Glidescope(®) video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airways.

Conflict of interest statement

None declared.

Figures

Fig. 1
Fig. 1
Study selection flow chart
Fig. 2
Fig. 2
Risk ratios (RR) of Cormack-Lehane (CL) grade 1 (vs ≥ grade 2) in clinical trials comparing Glidescope® video-laryngoscopy to direct laryngoscopy stratified by the difficulty of the intubation. Subjects were considered to have difficult intubations in studies that included patients with known prior difficult intubation, physical examination features suggesting difficult intubation, or in which difficult intubation was simulated by providing manual-in-line stabilization. The pooled estimate was derived using the DerSimonian and Laird random effects method with grey squares depicting individual study point estimates of the RR. Larger squares indicate a larger weight of the study when calculating the pooled estimate. Solid horizontal lines display the 95% confidence interval (CI) of the point estimate. Dashed vertical line represents an RR of 1.00, indicating no difference between Glidescope® video-laryngoscopy and direct laryngoscopy. Solid vertical lines represent the pooled estimates. Test for heterogeneity was significant using meta-regression analysis (P = 0.003). DL = direct laryngoscopy; GS = Glidescope®
Fig. 3
Fig. 3
Risk ratios (RR) of successful first-attempt intubation in clinical trials comparing Glidescope® video-laryngoscopy to direct laryngoscopy stratified by operator expertise (anesthesia or casualty consultants or house staff vs “other”). The pooled estimate was derived using the DerSimonian and Laird random effects method with grey squares depicting individual study point estimates of the RR. Larger squares indicate a larger weight of the study when calculating the pooled estimate. Solid horizontal lines display the 95% CI of the point estimate. Dashed vertical line represents an RR of 1.00, indicating no difference between Glidescope® video-laryngoscopy and direct laryngoscopy. Solid vertical lines represent the pooled estimates. Test for heterogeneity by operator expertise was significant using meta-regression analysis (P = 0.001). DL = direct laryngoscopy; GS = Glidescope®
Fig. 4
Fig. 4
Weighted mean difference (WMD), in seconds, in clinical trials comparing Glidescope® video-laryngoscopy to direct laryngoscopy stratified by operator expertise (anesthesia or casualty consultants or housestaff vs “other”). The pooled estimate was derived using the DerSimonian and Laird random effects method with grey squares depicting an individual study point estimate of the mean difference. Larger squares indicate a larger weight of the study when calculating the pooled estimate. Solid horizontal lines display the 95% CI of the point estimate. Dashed vertical line represents a WMD of 0, indicating no difference between Glidescope® video-laryngoscopy and direct laryngoscopy. Solid vertical lines represent the pooled estimate. Test for heterogeneity by operator expertise was significant using meta-regression analysis (P = 0.004)

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