Direct laryngoscopy versus videolaryngoscopy for neonatal tracheal intubation: An updated systematic review and meta-analysis

Introduction: The potential benefits and risks of Videolaryngoscopy (VL) over Direct Laryngoscopy (DL) in neonates undergoing tracheal intubation are unclear. Methods: We performed a systematic review and meta-analysis of randomized clinical trial (RCT) data comparing VL to DL in neonate patients following tracheal intubation, regarding the success rate of the first intubation attempt, mean number of intubation attempts, time to intubate, oxygen desaturation, bradycardia, airway trauma or bleeding and cardiopulmonary resuscitation. Results: Seven studies comprising 897 patients undergoing tracheal intubation were included. Of the participants studied, 450 (50,2 %) used VL and 447 (49,8 %) utilized DL. Overall, VL was associated with a higher first intubation success rate (RR: 1.18; p = 0.02; I-2 = 67 %) and fewer episodes of oxygen desaturation <90 % (RR: 0.84; p = 0.008; I-2 = 0 %). No differences were found in mean attempts to intubate (MD: 0.25; p = 0.188; I-2 = 99 %), time to intubate (MD: 1.327; p = 0.81; I-2 = 97 %), airway trauma or bleeding (RR: 0.69; p = 0.372; I-2 = 16 %), bradycardia <100 bpm (RR: 1.05; p = 0.81; I-2 = 0 %), and cardiopulmonary resuscitation (RR: 0.61; p = 0.447; I-2 = 74 %). Sub Analyses of first attempt intubation success rate in the intensive care unit (ICU) (RR: 1.48; p = 0.003; I-2 = 35 %) showed an advantage for VL. However, in bradycardia <60 bpm (RR: 0.89; p = 0.769; I-2 = 0 %) and oxygen desaturation <80 % (RR: 0.85; p = 0.066; I-2 = 0 %), VL and DL were equivalent. Conclusion: Despite the equivalence in some outcomes, in general, VL was superior to DL. This superiority was seen most clearly in the success rate of the first intubation and in the reduction in episodes of hypoxemia.