美国俄亥俄州克利夫兰诊所Daniel I. Sessler团队比较了视频喉镜检查和直接喉镜检查对患者手术预后的影响。2024年3月18日，《美国医学会杂志》发表了该项成果。

气管内插管通常在手术室使用直接喉镜检查。据报道，视频喉镜可以改善气道可视化；然而，改善的可视化是否会减少手术患者的插管尝试次数尚不清楚。为了确定当使用视频喉镜或直接喉镜进行初始喉镜检查时，每次手术的插管尝试次数是否较低，研究组在一家美国学术医院进行了一项集群随机多交叉临床试验。患者为18岁及以上的成年人，进行择期或紧急的心脏、胸部或血管外科手术，需要单腔气管插管进行全身麻醉。患者入组时间为2021年3月30日至2022年12月31日。数据分析基于意向治疗。

由两组11个手术室在1周的基础上随机分组，对首次插管尝试进行超角度视频喉镜或直接喉镜检查。主要结局是每次手术的手术室插管次数。次要结局是插管失败，定义为负责的临床医生在任何时候出于任何原因，或通过3次以上的插管尝试，切换到替代喉镜设备，以及气道和牙齿损伤的综合结局。

在7736名患者的8429次手术中，中位患者年龄为66岁（IQR，56-73），35%（2950）为女性，85%（7135）为择期手术。随机接受视频喉镜检查的4413例手术中，有77例（1.7%）需要1次以上插管，而随机接受直接喉镜检查的4016例手术中有306例（7.6%）需要插管，插管次数的估计比例优势比为0.20（95%CI，0.14-0.28；P < .001）。使用视频喉镜的4413例外科手术中有12例（0.27%）发生插管失败，而使用直接喉镜的4016例外科手术（4.0%）中有161例发生插管失败（相对风险，0.06；95%CI，0.03-0.14；P < .001），未经校正的绝对风险差为−3.7%（95%CI，−4.4%至−3.2%）。视频喉镜检查（41处损伤[0.93%]）与直接喉镜检查（42处损伤[1.1%]）之间的气道和牙齿损伤没有显著差异。

研究结果表明，在接受手术且全身麻醉需要单腔气管插管的成年人中，与美国单一学术医疗中心的直接喉镜检查相比，超角度视频喉镜检查减少了气管插管所需的尝试次数。结果表明，视频喉镜检查可能是为接受手术的患者插管的首选方法。

附：英文原文

Title: Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial

Author: Kurt Ruetzler, Sergio Bustamante, Marc T. Schmidt, Federico Almonacid-Cardenas, Andra Duncan, Andrew Bauer, Alparslan Turan, Nikolaos J. Skubas, Daniel I. Sessler, Collaborative VLS Trial Group, Jian Lin, Nikhil Kumar, Natasha Malackany, Yasdet Maldonado, John Apostolakis, Andrej Alfirevic, Marta Kelava, Jennifer Haargrave, Ria Richardson, David Anthony, Michelle Capdeville, Mariya Geube, Brett Wakefield, Nakul Kumar, Vera Burbano, Sandeep Khanna, Carlos Trombetta, Oscar Tovar-Camargo, Christopher Troianos, Edward Mascha, Yanyan Han, Dongsheng Yan, Julian Roessler, Elyad Ekrami, Esra Yalcin Kutlu

Issue&Volume: 2024-03-18

Abstract:

Importance  Endotracheal tubes are typically inserted in the operating room using direct laryngoscopy. Video laryngoscopy has been reported to improve airway visualization; however, whether improved visualization reduces intubation attempts in surgical patients is unclear.

Objective  To determine whether the number of intubation attempts per surgical procedure is lower when initial laryngoscopy is performed using video laryngoscopy or direct laryngoscopy.

Design, Setting, and Participants  Cluster randomized multiple crossover clinical trial conducted at a single US academic hospital. Patients were adults aged 18 years or older having elective or emergent cardiac, thoracic, or vascular surgical procedures who required single-lumen endotracheal intubation for general anesthesia. Patients were enrolled from March 30, 2021, to December 31, 2022. Data analysis was based on intention to treat.

Interventions  Two sets of 11 operating rooms were randomized on a 1-week basis to perform hyperangulated video laryngoscopy or direct laryngoscopy for the initial intubation attempt.

Main Outcomes and Measures  The primary outcome was the number of operating room intubation attempts per surgical procedure. Secondary outcomes were intubation failure, defined as the responsible clinician switching to an alternative laryngoscopy device for any reason at any time, or by more than 3 intubation attempts, and a composite of airway and dental injuries.

Results  Among 8429 surgical procedures in 7736 patients, the median patient age was 66 (IQR, 56-73) years, 35% (2950) were women, and 85% (7135) had elective surgical procedures. More than 1 intubation attempt was required in 77 of 4413 surgical procedures (1.7%) randomized to receive video laryngoscopy vs 306 of 4016 surgical procedures (7.6%) randomized to receive direct laryngoscopy, with an estimated proportional odds ratio for the number of intubation attempts of 0.20 (95% CI, 0.14-0.28; P<.001). Intubation failure occurred in 12 of 4413 surgical procedures (0.27%) using video laryngoscopy vs 161 of 4016 surgical procedures (4.0%) using direct laryngoscopy (relative risk, 0.06; 95% CI, 0.03-0.14; P<.001) with an unadjusted absolute risk difference of 3.7% (95% CI, 4.4% to 3.2%). Airway and dental injuries did not differ significantly between video laryngoscopy (41 injuries [0.93%]) vs direct laryngoscopy (42 injuries [1.1%]).

Conclusion and Relevance  In this study among adults having surgical procedures who required single-lumen endotracheal intubation for general anesthesia, hyperangulated video laryngoscopy decreased the number of attempts needed to achieve endotracheal intubation compared with direct laryngoscopy at a single academic medical center in the US. Results suggest that video laryngoscopy may be a preferable approach for intubating patients undergoing surgical procedures.

DOI: 10.1001/jama.2024.0762

Source: https://jamanetwork.com/journals/jama/fullarticle/2816267