Video vs. traditional laryngoscopy for tracheal intubation at birth or in the neonatal unit: A systematic review and meta-analysis

Background: Videolaryngoscopy may increase neonatal intubation success when used by neonatologists and anesthesiologists. It is not known if this is true for intubations by neonatal clinicians only in neonatal units or on delivery suites. Objective: To critically appraise evidence on the success of tracheal intubation with video laryngoscopy compared to traditional laryngoscopy in infants at birth or in a neonatal unit. Data sources: Systematic review of studies identified by MEDLINE, Embase, Cochrane Library, CINAHL and Clinical Trial Databases searched from inception to August 22, 2024, without language restrictions. Inclusion criteria: Studies that addressed the PICOST question: In infants receiving tracheal intubation at birth or on a neonatal unit (population), does video laryngoscopy (intervention), compared with traditional laryngoscopy (comparator), improve success (outcome)? Studies that included preoperative intubation or studies of video laryngoscopy use specifically for difficult airways were excluded. Study appraisal and synthesis methods: Risk of bias was assessed using Cochrane Risk of Bias 2 or ROBINS-I, meta-analysis using RevMan v. 5.4.1, and certainty of evidence using GRADEPro. Studied outcomes were successful tracheal intubation, successful intubation at first attempt, in-hospital mortality, adverse events attributed to laryngoscopy and perception of the intubating clinician. Results: Of 1261 records screened, six randomized controlled trials reporting 817 infants receiving 862 tracheal intubations were included. Success of intubation was higher overall with video laryngoscopy [relative risk 1.43; 95% confidence interval 1.15-1.77; p-value = 0.001; moderate certainty evidence] and at first attempt [relative risk 1.56; 95% confidence interval 1.33-1.84; p-value <0.001; high certainty evidence]. For mortality or adverse outcomes including airway trauma, esophageal intubation, desaturation <80%, bradycardia to either <60 or <100 beats/minute, clinical benefit or harm could not be excluded. Two randomised controlled trials reported intubator perceptions, but results could not be combined. Most of the first attempts in the randomised controlled trials were by inexperienced intubators. Four observational studies (3,289 infants; 3,342 intubations) showed increased success at first attempt with video laryngoscopy [relative risk 1.78; 95% confidence interval 1.16-2.74; p-value <0.001; very low certainty evidence]. Conclusion: For infants in the delivery room or neonatal unit, use of video laryngoscopy improved overall and first attempt intubation success.