Video vs traditional laryngoscopy for neonatal intubation: NLS: 5351 TF SR

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy.

Jasmine Antoine is completing a PhD on neonatal intubation training that includes video laryngoscopy {Antoine 2024 100776} and does not have any conflict of interest regarding the use of the tool in the clinical practice.

The following Task Force members have no conflicts of interest to declare: Joe Fawke, Ruth Guinsburg, Maria Fernanda de Almeida and Daniela Testoni Costa-Nobre.

CoSTR Citation

Fawke J, Antoine J, Costa-Nobre DT, Guinsburg R, Almeida MF, Schmölzer G, Weiner G, Liley HG on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Video vs traditional laryngoscopy for neonatal intubation [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2024 October 27. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

Ventilation of the lungs is key for a successful resuscitation at birth. Around 5% of newborn infants receive positive pressure ventilation in the delivery room and the great majority of them improve with ventilation applied by non-invasive interfaces {Ersdal 2012 869}. However, around 0.4-1.2% of neonates may require rapid endotracheal intubation to secure the airway, optimize oxygenation and achieve adequate ventilation immediately after birth {Bjorland 2019 e000592; Niles 2017 102}.

Several aspects of the neonatal anatomy, such as the small size of the mouth and airway, the disproportionately large tongue, epiglottis and arytenoids, and the keyhole appearance of the glottis complicate the process of endotracheal intubation. In addition, low pulmonary reserve and high oxygen consumption in preterm infants limit the time for the procedure {Lingappan 2018 CD009975}.

According to an international registry, 46% of endotracheal intubations are successful on the first attempt in the delivery room {Foglia 2019 e20180902}. There is great concern that changes in the clinical practice are negatively impacting current physicians’ competency in the procedure {Johnston 2021 434}, including the fact that tracheal aspiration is no longer recommended for infants born through meconium-stained amniotic fluid {Wyckoff 2020 S185} and there is a greater emphasis on the utilization of non-invasive ventilation strategies for preterm infants {Sweet 2023 3}.

Besides the concern with unsuccessful endotracheal intubation, the frequency of adverse events associated with the procedure has been increasingly studied. In an international registry, among 598 endotracheal intubations in the delivery room, adverse events occurred in 103 (17%). In 27

procedures, the events were classified as severe, such as late recognition of esophageal intubation, laryngospasm, air leaks and airway trauma, among others. Severe desaturations occurred in 134 of 426 procedures (31%) and they were defined as ≥20% decrease in oxygen saturation from the highest level achieved immediately before the first attempt {Foglia 2019 e20180902}.

Therefore, health professionals face a stressful scenario of a life-saving procedure that may be unsuccessful and/or lead to important adverse events, requiring skilled providers, in a context of few opportunities to practice endotracheal intubation. The availability of video laryngoscopy could facilitate the training and the procedure in the clinical setting. It may also be useful in infants who are perceived to have a difficult airway {Gupta 2021 14}.

To accomplish endotracheal intubation using traditional laryngoscopy, there must be an unobstructed view from the eye of the practitioner to the laryngeal inlet. Video laryngoscopes allow for visualization of the glottis without the need to align the site of vision in a linear fashion with the laryngeal inlet. The blade of a video laryngoscope has a video camera and a light source at its tip enabling the transmission of glottis’ image to the operator. A liquid crystal display screen is mounted on the handle of the device or as a separate screen for visualization of the glottis {Balaban 2017 477}.

The first attempt to elucidate the advantages of video laryngoscopy in adults was reported in 2003 {Kaplan 2003 E025}. Around the same time, new types of video laryngoscopes, suitable for pediatric use, were introduced and they have shown encouraging results in randomized controlled trials {Riva 2023 101}. However, their exact role at present remains unclear in this population {Gupta 2021 14}. Video laryngoscopy is a heterogeneous term covering a range of different devices and effectiveness might vary. Besides the devices themselves, the age of the patients, type of intubation (oral vs. nasal) and the experience of the providers also influence the performance of the video laryngoscopes during endotracheal intubation {de Carvalho 2022 1000}.

The first report of the use of video laryngoscopy in newborn infants occurred in 2009 {Vanderhal 2009 e339}. The authors described the video laryngoscopy equipment and the technique for endotracheal intubation and airway evaluation in the delivery room and in the neonatal intensive care unit (NICU) in 47 patients who weighed 530-6795g and concluded that the new equipment showed promise to improve airway management, evaluation, and teaching {Vanderhal 2009 e339}. Since then, endotracheal intubation assisted by video laryngoscopy has been increasingly used. In a research involving NICU (n=2009) and delivery room (n=598) endotracheal intubations from 10 international centers, the use of video laryngoscopy occurred in, respectively, 21% and 11% {Foglia 2019 e20180902}. An UK survey of 169 neonatal units showed that 63% (107/169) of them have a video laryngoscope and 31% (33/107) of these units use it as first-line equipment when intubating {Thomas 2023 89}.

A Cochrane systematic review {Lingappan 2023 CD009975} compared video to traditional laryngoscopy in decreasing the time and attempts required for endotracheal intubation and increasing the success rate at first intubation in neonates. The authors collected information on newborn infants who required endotracheal intubation in the delivery room, operating room or in the intensive care unit. They found eight studies: three of them enrolled newborns in the neonatal unit {Bartle 2019 252; Moussa 2016 e20152156; Volz 2018 1074}, one enrolled infants both in the delivery room and in the neonatal unit {O’Shea 2015 912} and four of them studied infants in the operating room {Kamath 2020 24; Salama 2019 28; Singh 2009 338; Tao 2019 482}. The systematic review {Lingappan 2023 CD009975} concluded that video laryngoscopy may increase the success of endotracheal intubation on the first attempt and may result in fewer intubation attempts but may not reduce the time required for successful intubation in newborn infants (low-certainty evidence).

In the literature, intubation competency has been defined as provider success intubating on the first or second attempt ≥80% of the time {Falck 2003 1242}. Video laryngoscopy has been increasingly applied in health professionals’ training as it allows the supervisor to see what the provider is viewing {Antoine 2024 100006; Dias 2021 e2020005009}. In a systematic review of studies that compared the performance of trainees, video laryngoscopy and real-time supervisor feedback was more effective for supporting the development of neonatal intubation skills, compared with traditional laryngoscopy {MacKinnon 2023 111}. However, there is conflicting evidence in the simulation setting as to whether video laryngoscopy is superior to traditional laryngoscopy when used as a teaching tool {Antoine 2024 10776; Nair 2017 e962; Parmekar 2017 979; Dias 2021 e2020005009}.

Based on the available information, the European Resuscitation Council guidelines concluded that the effectiveness of video laryngoscopy in the context of resuscitation at birth has not been fully evaluated {Madar 2021 291}. The American Academy of Pediatrics’ Neonatal Resuscitation Program (NRP), in 2021, stated that “a videolaryngoscope may be a helpful device for training novice operators and for intubating a baby with a difficult airway” {Weiner 2021}. There are no recommendations about video laryngoscope use by any of the ILCOR Task Forces. Therefore, as part of its continuous evaluation process, the ILCOR Neonatal Life Support Task Force prioritized this topic for a systematic review.

Systematic Review

Fawke J, Antoine J, Costa-Nobre DT, Guinsburg R, Almeida MF, Schmölzer G, Weiner G, Liley HG on behalf of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Video vs traditional laryngoscopy for neonatal intubation: A systematic review.

PICOST

Population: Infants receiving endotracheal intubation at birth or on a neonatal unit

Intervention: Endotracheal intubation using video laryngoscopy

Comparators: Endotracheal intubation using traditional laryngoscopy

Outcomes:

Primary:

• Successful endotracheal intubation (Yes/No) (Important)

Secondary:

• Successful endotracheal intubation at the first attempt (Important)
• Number of attempts to achieve successful endotracheal intubation (Important)
• Time taken to successfully intubate (Important)
• Adverse events around the time of laryngoscopy e.g., airway trauma, bradycardia, desaturation, esophageal intubation, pneumothorax (Important)
• Perception of intubating clinician e.g., intubation difficulty (as defined by author) (Important)
• Mortality in-hospital (Critical)
• Any intraventricular hemorrhage (IVH) (preterm only) (Important)

Outcomes ratings using the GRADE classifications of critical or important were decided according to a consensus for international neonatal resuscitation guidelines {Strand 2020 328}.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) were eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. The literature search was first done on November 13, 2023, and updated on August 22, 2024.

DEFINITIONS

Primary outcome definition: successful intubation, defined as the placement of a tracheal tube in the trachea

Laryngoscopy:

• Traditional: direct visualization of the larynx by the intubating clinician using a handheld laryngoscope without the use of a screen
• Video: indirect visualization of the larynx by the intubating clinician or supervising clinician using a handheld laryngoscope with the use of a screen

Laryngoscope

• Traditional: a handheld device placed over the tongue and used to visualize the larynx, it includes a light source but does not include a camera or video screen
• Video: a handheld device placed over the tongue and used to visualize the larynx, it includes a light source and a camera or video. A video screen is mounted on the handle of the device or as a separate screen. It can also be used in a traditional way if the video screen is not used

Intubation attempt: as defined by author

Time to intubate: time from inserting laryngoscope blade into infant’s mouth to confirmation of successful endotracheal intubation

Esophageal intubation: a tracheal tube that has been placed into the esophagus instead of the trachea

Difficult airway: a clinical situation where a healthcare provider who is skilled at airway management encounters difficulty with one or more standard methods of airway management {Kollmeier 2023}. The definition is not standardized in the literature and there are some variations between national expert guidelines.

Adverse events around the time of laryngoscopy:

Airway trauma: soft tissue injury to the airway, pharynx or epiglottis

Bradycardia: a slow heart rate as defined by the author

Desaturation: a decrease in oxygen saturation as defined by the author

Endotracheal intubation:

• Oral: an endotracheal tube passed through the mouth and through the vocal cords
• Nasal: an endotracheal tube passed through the nose and nasopharynx, and placed through the vocal cords, usually with the help of Magills forceps or similar

Air leak / Pneumothorax: an air leak into the pleural space during initial hospital stay

IVH: intraventricular haemorrhage graded as per Papile criteria {Papile 1978 529}

A PRIORI SUBGROUPS:

• Location – delivery room or neonatal unit
• Emergency vs. elective intubation
• Gestational age: ≥37+0 weeks; 28+0 to 36+6 weeks and < 28+0 weeks
• Experience of person handling the laryngoscope as defined by the author
• Type of laryngoscope (e.g., different blade shape, different video screen)

PROSPERO REGISTRATION: CRD42023467940

RISK OF BIAS

• Randomized controlled trials: Cochrane Risk of Bias 2 instrument for each outcome {Sterne 2019 I4898}
• Observational non-randomized studies: ROBINS-I tool for each study {Sterne 2016 i4919}

Consensus on Science

The systematic review identified 6 RCTs involving 817 infants receiving 862 endotracheal intubations {Bartle 2019 195; Geraghty 2024 1885; Moussa 2016 e20152156; O´Shea 2015 912; Tippmann 2023 e001958; Volz 2018, 1074} and 4 observational studies involving 3289 infants receiving 3342 endotracheal intubations {Lacquiere 2024 476; Moussa 2022 1210; O´Shea 2021 168; Tippmann 2021 675238}. Three RCTs enrolled infants only in the NICU {Bartle 2019 195; Moussa 2016 e20152156; Volz 2018 1074}, and three in the NICU and delivery room {Geraghty 2024 1885; O´Shea 2015 912; Tippmann 2023 e001958}. For the observational studies, one enrolled infants only in the NICU {Moussa 2022 1210}, two in the NICU and delivery room {O´Shea 2021 168; Tippmann 2021 675238}, and one included endotracheal intubations prior to neonatal transport {Lacquiere 2024 476}. Outcomes were described by intubation not by infants.

For the comparison between video laryngoscopy versus traditional laryngoscopy:

The important outcome of successful endotracheal intubation, showed clinical benefit (Relative Risk (RR) 1.43; 95% Confidence Interval (CI) 1.15 to 1.77, I²=50%, or 220 more successful endotracheal intubations/1000 with video laryngoscopy [95%CI, 77 more to 395 more]), traditional laryngoscopy event rate 513/1000, videolaryngoscopy event rate 733/1000 number needed to treat 4.5, high certainty evidence from 4 RCTs involving 567 intubations {Bartle 2019 195; Geraghty 2024 1885; Moussa 2016 e20152156; Volz 2018 1074}.

The important outcome of successful endotracheal intubation at first attempt, showed clinical benefit (RR 1.57; 95%CI 1.33 to 1.85; I²=0%, or 225 more successful endotracheal intubation at first attempt/1000 with video laryngoscopy [95%CI, 130 more to 335 more]), traditional laryngoscopy event rate 394/1000, videolaryngoscopy event rate 618/1000 number needed to treat 4.5, high certainty evidence from 4 RCTs involving 610 intubations {Geraghty 2024 1885; O´Shea 2015 912; Tippmann 2023 e001958; Volz 2018 1074}. From the observational studies, there was possible clinical benefit from using video laryngoscopy (RR 1.78; 95%CI 1.16 to 2.74; I²=95%, or 354 more successful endotracheal intubations at first attempt/1000 with video laryngoscopy [95%CI, 73 more to 789 more] compared to traditional laryngoscopy, very low certainty evidence (downgraded for serious risk of bias, serious inconsistency and very serious imprecision) from 4 studies involving 3342 intubations {Lacquiere 2024 476; Moussa 2022 1210; O´Shea 2021 168; Tippmann 2021 675238}.

For the important outcome of number of attempts to intubate, clinical benefit or harm could not be excluded, moderate certainty evidence (downgraded for serious risk of bias). The results were not estimable due to the heterogeneous approach to the statistical analysis in 4 RCTs involving 555 intubations {Bartle 2019 195; Geraghty 2024 1885; Moussa 2016 e20152156; Tippmann 2023 e001958}.

For the important outcome of time to successful endotracheal intubation (in seconds), clinical benefit or harm could not be excluded, very low certainty evidence (downgraded for very serious risk of bias and serious imprecision) from 4 RCTs involving 734 intubations {Geraghty 2024 1885; Moussa 2016 e20152156; O´Shea 2015 912; Volz 2018 1074}. Meta-analysis was not possible due to the heterogeneity in the reported measurements. However, the raw data showed that video took slightly longer than the traditional laryngoscopy in two RCTs {Geraghty 2024 1885; Moussa 2016 e20152156}, whilst traditional laryngoscopy took slightly longer in the other two RCTs {O´Shea 2015 912; Volz 2018 1074}. The time differences in both cases were small. One RCT with 214 intubations reported the time to successfully intubate at first attempt {Geraghty 2024 1885}, and three RCTs with 520 intubations reported the time for each intubation attempt that was successful with video and traditional laryngoscopy, but cumulative time to successfully intubate the patients was not reported {Moussa 2016 e20152156; O´Shea 2015 912; Volz 2018 1074}.

For the important outcome of adverse events during laryngoscopy, clinical benefit or harm could not be excluded, very low certainty evidence (downgraded for serious risk of bias and very serious inconsistency) from 5 RCTs involving 823 intubations {Geraghty 2024 1885; Moussa 2016 e20152156; O´Shea 2015 912; Tippmann 2023 e001958; Volz 2018 1074}. The results were not estimable for all adverse events together. Therefore, analyses of adverse events are reported individually for airway trauma, bradycardia (heart rate<100 bpm and heart rate<60 bpm), oxygen saturation <80%, esophageal intubation, and pneumothorax.

For the important outcome of airway trauma, clinical benefit or harm could not be excluded (RR 0.76; 95%CI 0.27 to 2.16; I²= 23%, or 8 fewer airway trauma/1000 with video laryngoscopy [95%CI, 24 fewer to 39 more airway trauma/1000 with video laryngoscopy]), very low certainty evidence (downgraded for very serious risk of bias and serious inconsistency) from 4 RCTs involving 601 intubations {Geraghty 2024 1885; Moussa 2016 e20152156; Tippmann 2023 e001958; Volz 2018 1074}. Regarding observational studies, clinical benefit or harm could not be excluded (RR 0.52; 95%CI 0.24 to 1.15; I²= 66%, or 9 fewer airway trauma/1000 with video laryngoscopy [95%CI, 15 fewer to 3 more]), very low certainty evidence (downgraded for serious risk of bias, serious inconsistency and very serious imprecision) from 2 studies, involving 2980 intubations {Moussa 2022 1210; Tippmann 2021 675238}.

For the important outcome of bradycardia (heart rate <100bpm), clinical benefit or harm could not be excluded (RR 0.97; 95%CI 0.61 to 1.55; I²=0%, or 6 fewer bradycardia with heart rate <100 bpm/1000 with video laryngoscopy [95% CI, 76 fewer to 108 more]), moderate certainty evidence (downgraded for serious risk of bias) from 2 RCTs involving 287 intubations {Geraghty 2024 1885; Tippmann 2023 e001958}.

For the important outcome of bradycardia (heart rate <60bpm), clinical benefit or harm could not be excluded (RR 0.90; 95%CI 0.40 to 2.01; I²=0%, or 8 fewer bradycardia with heart rate <60 bpm/1000 with video laryngoscopy [95% CI 49 fewer to 82 more]), moderate certainty evidence (downgraded for serious risk of bias) from 2 RCTs involving 287 intubations {Geraghty 2024 1885; Tippmann 2023 e001958}.

For the important outcome of oxygen saturation <80%, clinical benefit or harm could not be excluded (RR 0.84; 95%CI 0.70 to 1.00; I²=0%, or 105 fewer oxygen saturation<80%/1000 with video laryngoscopy [95% CI, 197 fewer to 0 more]), moderate certainty evidence (downgraded for serious risk of bias) from 2 RCTs involving 287 intubations {Geraghty 2024 1885; Tippmann 2023 e001958}.

For the important outcome of esophageal intubation, clinical benefit or harm could not be excluded (RR 0.49; 95%CI 0.16 to 1.50; I²=56%, or 61 fewer esophageal intubations/1000 with video laryngoscopy [95%CI, 101 fewer to 60 more]), low certainty evidence (downgraded for very serious risk of bias) from 3 RCTs involving 403 intubations {Moussa 2016 e20152156; Tippmann 2023 e001958; Volz 2018, 1074}. Observational studies showed possible clinical benefit (RR 0.29; 95%CI 0.10 to 0.84; I²=95%, or 97 fewer esophageal intubations/1000 with video laryngoscopy [95% CI, 123 fewer to 22 fewer]), low certainty evidence (downgraded for very serious risk of bias and serious imprecision) from 2 studies} involving 2980 intubations {Moussa 2022 1210; Tippmann 2021 675238}.

For the important outcome of pneumothorax, the clinical effect could not be estimated with two RCTs {Tippmann 2023 e001958, Volz 2018 1074} reporting no episodes of pneumothorax in video laryngoscopy vs 1 case in traditional laryngoscopy over 190 intubations. Regarding observational studies, clinical benefit or harm could not be excluded (RR 0.26; 95%CI 0.05 to 1.38; I²= 0%, or 7 fewer pneumothorax/1000 with video laryngoscopy [95%CI, 10 fewer to 4 more]), low certainty evidence (downgraded for very serious risk of bias) from 2 studies involving 2980 intubations {Moussa 2022 1210; Tippmann 2021 675238}.

For the important outcome of perception of intubating clinician, clinical benefit or harm could not be excluded. The results were not estimable to the heterogeneous approach to this outcome 2 RCTs involving 252 intubations {Bartle 2019 2288; Moussa 2016 2392}. One RCT {Bartle 2019 2288} reported a confidence score varying from 0-100% of trainees, trainers and supporting staff in median and interquartile range (IQR) in 39 endotracheal intubations: trainee confidence - VL 99% (6%) vs. TL 86.5% (43%); trainer confidence - VL 94% (10%) vs. TL 86% (19%); and supporting staff confidence - VL 88.5% (11%) vs. TL 74% (35%). Another RCT {Moussa 2016 2392} reported on difficulty of intubation as perceived by provider: inserting endotracheal tube - VL 6/101 (6%) vs. TL 9/112 (8%); visualizing glottis - VL 8/101 (8%) vs. TL 19/112 (17%); and blade too big - VL 5/101 (5%) vs. TL 0. No observational studies reported on perception of intubating clinicians.

For the critical outcome of mortality in-hospital, clinical benefit or harm could not be excluded (RR 0.50; 95%CI 0.05 to 5.43; I²=0%, or 6 fewer hospital deaths/1000 with video laryngoscopy [95%CI, 12 fewer to 57 more]), moderate certainty evidence (downgraded for risk of bias) from 2 RCTs involving 303 intubations {Geraghty 2024 1885; Tippmann 2023 e001958}. One RCT, with 214 infants {Geraghty 2024 1885}, reported one death in the video laryngoscopy group (hydrops fetalis) and two in the traditional laryngoscopy group (twin-to-twin transfusion syndrome and severe congenital heart disease). None of them were related to endotracheal intubation. The other RCT with 63 infants and 89 intubations reported no deaths {Tippmann 2023 e001958}.

For the important outcome of any intraventricular hemorrhage, the clinical effect could not be estimated with one RCT {Tippmann 2023 e001958} reporting no events over 89 intubations, and one observational study {Tippmann 2021 675238} reporting no events in the video laryngoscopy group over 56 intubations and one event in the traditional laryngoscopy group over 194 intubations

Regarding subgroups analyses, no data were reported to perform subgroup analysis by location of endotracheal intubation (delivery room or neonatal unit), type of intubation (emergency vs. elective), gestational age (≥37+0, 28+0 to 36+6 and < 28+0 weeks), experience of the person handling the laryngoscope and type of laryngoscope. Although two RCTs used one brand of video laryngoscope {O´Shea 2015 912; Tippmann 2023 e001958} and 4 RCTs {Bartle 2019 195; Geraghty 2024 1885; Moussa 2016 e20152156; Volz 2018, 1074} used another brand, they lacked sufficient details regarding models, screen size or whether screens were attached to the laryngoscope handle or separate. As a result, subgroup analysis of brands could not be made.

Treatment Recommendations

Where resources and training allow, in infants being intubated at birth or on a neonatal unit, we suggest the use of video laryngoscopy in comparison to traditional laryngoscopy, especially in settings where less experienced staff are intubating (conditional recommendation, high certainty of evidence). Traditional laryngoscopy remains a reasonable option as no increased harm was shown compared to video laryngoscopy (weak recommendation, very low certainty of evidence).

A traditional laryngoscope should always be available as a backup device (good practice statement).

Justification and Evidence to Decision Framework Highlights

In making this conditional recommendation, the NLS Task Force considered the systematic review evidence from 6 RCTs {Bartle 2019 195; Geraghty 2024 1885; Moussa 2016 e20152156; O´Shea 2015 912; Tippmann 2023 e001958; Volz 2018, 1074} with 862 endotracheal intubations and high certainty evidence that favored video laryngoscopy over traditional laryngoscopy for the outcomes of successful endotracheal intubation and successful endotracheal intubation at first attempt. These findings are supported by 4 observational studies {Lacquiere 2024 476; Moussa 2022 1210; O´Shea 2021 168; Tippmann 2021 675238} with 3342 endotracheal intubations and very low certainty evidence that favored video laryngoscopy over traditional laryngoscopy for the outcome of successful intubation at the first attempt.

• There was no difference in a range of adverse events when using a video laryngoscope compared to a traditional laryngoscope. The RCTs mainly enrolled infants without airway congenital anomalies who were intubated by less experienced staff or in training neonatologists, whether in the delivery room or in the neonatal unit, excluding all studies that reported intubations by anesthesiologists. The reason for this was to provide focused information about the use of video laryngoscopes by neonatal staff. The observational studies included a wider range of experience among intubating clinicians.
• It should be recognized that video laryngoscopes are expensive and will not be available in all settings. Traditional laryngoscopy remains a good alternative for neonatal endotracheal intubations on neonatal units and delivery rooms and should always be available.

Knowledge Gaps

Studies are needed to advance knowledge regarding the use of videolaryngoscopy, in comparison with traditional laryngoscopy, such as:

• Efficacy, effectiveness and safety in decreasing number of intubation attempts
• Efficacy, effectiveness and safety in decreasing time to successful intubation
• Efficacy, effectiveness and safety in different gestational ages
• Efficacy, effectiveness and safety at birth, in the delivery room
• Efficacy, effectiveness and safety in emergent endotracheal intubations
• Efficacy, effectiveness and safety of the different types of video laryngoscopes (e.g., different blade shape, whether video screen attached to handle or detached, size of screen)

• Benefits of video laryngoscopy among more experienced intubators
• Cost effectiveness of video laryngoscope use
• Feasibility of video laryngoscope use in different settings

ETD summary table: NLS 5351 Et DVL vs Std L 2024

References

Antoine J, Dunn B, McLanders M, Jardine L, Liley H. Approaches to neonatal intubation training: A scoping review. Resuscitation Plus. 2024; 20:100776. https://doi.org/10.1016/j.resp....

Balaban O, Tobias JD. Videolaryngoscopy in neonates, infants, and children. Pediatr Crit Care Med. 2017;18(5):477-485. doi: 10.1097/PCC.0000000000001128.

Bartle DG, Powell R, Pearson K, Adeboye TS. Video vs direct laryngoscopy. Success rates and confidence: a feasibility study. Infant 2019;15(5):1-4. doi: 10.1007/s12630-016-0792-x.

Bjorland PA, Øymar K, Ersdal HL, Rettedal SI. Incidence of newborn resuscitative interventions at birth and short-term outcomes: a regional population-based study. BMJ Paediatr Open. 2019;3(1):e000592. doi: 10.1136/bmjpo-2019-000592

de Carvalho CC, Regueira SLPA, Souza ABS, Medeiros LMLF, Manoel MBS, da Silva DM, et al. Videolaryngoscopes versus direct laryngoscopes in children: ranking systematic review with network meta-analyses of randomized clinical trials. Paediatr Anaesth. 2022;32(9):1000-1014. doi: 10.1111/pan.14521.

Dias PL, Greenberg RG, Goldberg RN, Fisher K, Tanaka DT. Augmented reality-assisted video laryngoscopy and simulated neonatal intubations: a pilot study. Pediatrics. 2021;147(3):e2020005009. doi: 10.1542/peds.2020-005009.

Ersdal HL, Mduma E, Svensen E, Perlman JM. Early initiation of basic resuscitation interventions including face mask ventilation may reduce birth asphyxia related mortality in low-income countries: a prospective descriptive observational study. Resuscitation. 2012;83(7):869-73. doi: 10.1016/j.resuscitation.2011.12.011

Falck AJ, Escobedo MB, Baillargeon JG, Villard LG, Gunkel JH. Proficiency of pediatric residents in performing neonatal endotracheal intubation. Pediatrics. 2003;112(6 Pt 1):1242-7. doi: 10.1542/peds.112.6.1242 .

Foglia EE, Ades A, Sawyer T, Glass KM, Singh N, Jung P, et al; NEAR4NEOS Investigators. Neonatal intubation practice and outcomes: an international registry study. Pediatrics. 2019;143(1):e20180902. doi: 10.1542/peds.2018-0902

Geraghty LE, Dunne EA, Ní Chathasaigh CM, Vellinga A, Adams NC, O'Currain EM, McCarthy LK, O'Donnell CPF. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med. 2024 May 30;390(20):1885-1894. doi: 10.1056/NEJMoa2402785.

Gupta A, Sharma R, Gupta N. Evolution of videolaryngoscopy in pediatric population. J Anaesthesiol Clin Pharmacol. 2021;37(1):14-27. doi: 10.4103/joacp.JOACP_7_19.

Johnston L, Sawyer T, Ades A, Moussa A, Zenge J, Jung P, et al; NEAR4NEOS Investigators. Impact of physician training level on neonatal tracheal intubation success rates and adverse events: a report from national emergency airway registry for neonates (NEAR4NEOS). Neonatology. 2021;118(4):434-442. doi: 10.1159/000516372

Kamath N, Dogra N, Gupta A. Comparison of ease of intubation with airtraq optical laryngoscope versus Miller laryngoscope in neonates – a randomised interventional study. Ind J Anaesth. 2020;64 (Suppl 1):S24-5.

Kaplan MB, Ward DS, Berci G. A new video laryngoscope - an aid in intubation and teaching. J Educ Perioper Med. 2003;5(1):E025.

Kollmeier BR, Boyette LC, Beecham GB, et al. Difficult Airway. [Updated 2023 Apr 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/b....

Lacquiere D, Smith J, Bhanderi N, Lockie F, Pickles J, Steere M, Craven J, Mazur S. Early experience in use of videolaryngoscopy by a neonatal pre-hospital and retrieval service. Emerg Med Australas. 2024;36(3):476-478. doi: 10.1111/1742-6723.14374.

Lingappan K, Neveln N, Arnold JL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database Syst Rev. 2023 May 12;5(5):CD009975. doi: 10.1002/14651858.CD009975.pub4.

MacKinnon J, McCoy C. Use of video laryngoscopy versus direct laryngoscopy as a teaching tool for neonatal intubation: A systematic review. Can J Respir Ther. 2023;59:111-116. doi: 10.29390/cjrt-2022-056.

Madar J, Roehr CC, Ainsworth S, Ersdal H, Morley C, Rüdiger M, et al. European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth. Resuscitation. 2021;161:291-326. doi: 10.1016/j.resuscitation.2021.02.014.

Moussa A, Luangxay Y, Tremblay S, Lavoie J, Aube G, Savoie E, et al. Videolaryngoscope for teaching neonatal endotracheal intubation: a randomized controlled trial. Pediatrics. 2016;137(3):e20152156. doi: 10.1542/peds.2015-2156.

Moussa A, Sawyer T, Puia-Dumitrescu M, Foglia EE, Ades A, Napolitano N, Glass KM, Johnston L, Jung P, Singh N, Quek BH, Barry J, Zenge J, DeMeo S, Mehrem AA, Nadkarni V, Nishisaki A; National Emergency Airway Registry for Neonates (NEARNEOS) investigators. Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS. J Perinatol. 2022;42(9):1210-1215. doi: 10.1038/s41372-022-01472-9.

Nair S, Thomas EJ, Katakam L. Video laryngoscopy vs. direct laryngoscopy in teaching neonatal endotracheal intubation: a simulation-based study. Cureus. 2017;9(1):e962. doi: 10.7759/cureus.962.

Niles DE, Cines C, Insley E, Foglia EE, Elci OU, Skåre C, et al. Incidence and characteristics of positive pressure ventilation delivered to newborns in a US tertiary academic hospital. Resuscitation. 2017;115:102-109. doi: 10.1016/j.resuscitation.2017.03.035

O'Shea JE, Thio M, Kamlin CO, McGrory L, Wong C, John J, et al. Videolaryngoscopy to teach neonatal intubation: a randomized trial. Pediatrics. 2015;136(5):912-9. doi: 10.1542/peds.2015-1028.

O'Shea JE, Kirolos S, Thio M, Kamlin COF, Davis PG. Neonatal videolaryngoscopy as a teaching aid: the trainees' perspective. Arch Dis Child Fetal Neonatal Ed. 2021;106(2):168-171. doi: 10.1136/archdischild-2020-319619.

Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978 Apr;92(4):529-34. doi: 10.1016/s0022-3476(78)80282-0

Parmekar S, Arnold JL, Anselmo C, Pammi M, Hagan J, Fernandes CJ, et al. Mind the gap: can videolaryngoscopy bridge the competency gap in neonatal endotracheal intubation among pediatric trainees? a randomized controlled study. J Perinatol. 2017;37(8):979-983. doi: 10.1038/jp.2017.72.

Riva T, Engelhardt T, Basciani R, Bonfiglio R, Cools E, Fuchs A, et al; OPTIMISE Collaboration. Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial. Lancet Child Adolesc Health. 2023;7(2):101-111. doi: 10.1016/S2352-4642(22)00313-3

Salama ER, El Amrousy D. GlideScope^® cobalt video laryngoscope versus direct Miller laryngoscope for lateral position-tracheal intubation in neonates with myelodysplasia: A prospective randomized study. Saudi J Anaesth. 2019;13(1):28-34. doi: 10.4103/sja.SJA_460_18.

Singh R, Singh P, Vajifdar H. A comparison of Truview infant EVO2 laryngoscope with the Miller blade in neonates and infants. Paediatr Anaesth. 2009;19(4):338-42. doi: 10.1111/j.1460-9592.2009.02929.x.

Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hróbjartsson A, Kirkham J, Jüni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Schünemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JP. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. doi: 10.1136/bmj.i4919.

Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, Emberson JR, Hernán MA, Hopewell S, Hróbjartsson A, Junqueira DR, Jüni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366:l4898. doi: 10.1136/bmj.l4898.

Strand ML, Simon WM, Wyllie J, Wyckoff MH, Weiner G. Consensus outcome rating for international neonatal resuscitation guidelines. Arch Dis Child Fetal Neonatal Ed. 2020;105(3):328-330. doi: 10.1136/archdischild-2019-316942.

Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et al. European consensus guidelines on the management of respiratory distress syndrome: 2022 update. Neonatology. 2023;120(1):3-23. doi: 10.1159/000528914.

Tao B, Liu K, Zhao P, Wang D, Liu Y, Yin H. Comparison of GlideScope video laryngoscopy and direct laryngoscopy for tracheal intubation in neonates. Anesth Analg. 2019;129(2):482-486. doi: 10.1213/ANE.0000000000003637.

Tippmann S, Haan M, Winter J, Mühler AK, Schmitz K, Schönfeld M, Brado L, Mahmoudpour SH, Mildenberger E, Kidszun A. Adverse Events and Unsuccessful Intubation Attempts Are Frequent During Neonatal Nasotracheal Intubations. Front Pediatr. 2021;9:675238. doi: 10.3389/fped.2021.675238.

Tippmann S, Schäfer J, Winter J, Mühler AK, Schmitz K, Schönfeld M, Eichinger M, Mildenberger E, Kidszun A. Video versus direct laryngoscopy to improve the success rate of nasotracheal intubations in the neonatal intensive care setting: a randomised controlled trial. BMJ Paediatr Open. 2023;7(1):e001958. doi: 10.1136/bmjpo-2023-001958.

Thomas H, Lugg R, James B, Geeroms C, Risbridger A, Bell R, et al. Survey of the use of videolaryngoscopy in neonatal units in the UK. Arch Dis Child Fetal Neonatal Ed. 2023;108(1):89-90. doi: 10.1136/archdischild-2021-322813.

Vanderhal AL, Berci G, Simmons CF Jr, Hagiike M. A videolaryngoscopy technique for the intubation of the newborn: preliminary report. Pediatrics. 2009;124(2):e339-46. doi: 10.1542/peds.2008-3653.

Volz S, Stevens TP, Dadiz R. A randomized controlled trial: does coaching using video during direct laryngoscopy improve residents' success in neonatal intubations? J Perinatol. 2018;38(8):1074-1080. doi: 10.1038/s41372-018-0134-7.

Weiner GM. Textbook of neonatal resuscitation. 8^th ed. Itasca, IL: American Academy of Pediatrics; 2021.

Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, et al; Neonatal Life Support Collaborators. Neonatal Life Support: 2020 International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2020;142(16_suppl_1):S185-S221. doi: 10.1161/CIR.0000000000000895

Appendix: Search Strategy

PubMed/Medline search strategy: The literature search was first done on November 13, 2023, and updated on August 22, 2024.

Similar for: Embase, Cochrane and CINAHL

("Infant"[Mesh] OR infant*[tiab] OR newborn*[tiab] OR "new born*"[tiab] OR "Infant, Newborn"[Mesh] OR neonat*[tiab] OR neo-nat*[tiab] OR "newly born"[tiab] OR premature[tiab] OR prematurity[tiab] OR preterm[tiab] OR "pre term"[tiab] OR "Premature Birth"[Mesh] OR "low birth weight"[tiab] OR "low birthweight"[tiab] OR VLBW[tiab] OR LBW[tiab] OR postnatal[tiab] OR post-natal[tiab] OR "golden hour"[tiab] OR "Perinatal Care"[Mesh]

AND (((video*[tiab] OR screen*[tiab] OR camera*[tiab] OR indirect[tiab]) AND (laryngoscop*[tiab] OR "Laryngoscopy"[Mesh] OR "Laryngoscopes"[Mesh])) OR (videolaryngoscop*[tiab] OR Glidescope[tiab] OR McGrath[tiab] OR Pentax[tiab] OR 'airway scope'[tiab] OR C‐MAC[tiab] OR Truview[tiab] OR Airtraq[tiab] OR 'optical laryngoscope'[tiab] OR 'LMA Ctrach'[tiab] OR Neoview[tiab] OR parker[tiab] OR koala[tiab]))

AND (Intubation[MeSH] OR intubat*[tiab])