Video laryngoscopy vs. direct laryngoscopy for nasotracheal intubation in oromaxillofacial surgery: a systematic review and meta-analysis of randomized controlled trials

Abstract

Background: Nasotracheal intubation (NTI) is commonly performed in oromaxillofacial surgeries. We did this metanalysis to ascertain whether use of video laryngoscopy (VL) provided better NTI characteristics as compared to direct laryngoscopy (DL) in patients undergoing oromaxillofacial surgeries.Methods: We performed a systematic search to identify randomized controlled trials comparing VL with DL for NTI in adults undergoing elective oromaxillofacial surgery. The primary outcome was time to intubation. Secondary outcomes included the first attempt success, overall success, incidence of nasal bleeding, Cormack and Lehane grade, and maneuvers required. Results: Of the 456 studies identified following a systematic search, 10 were included. Meta-analysis showed a significantly lower time to tracheal intubation favoring VL (mean difference: –9.04, 95% CI [–12.71, –5.36], P < 0.001; I2 = 59%). VL was also associated with a greater first attempt success (relative risk [RR]: 1.10, 95% CI [1.04, 1.16], P = 0.001). Maneuvers to facilitate intubation were less with VL (RR: 0.22, 95% CI [0.10, 0.51], P < 0.001). There was no difference in overall intubation success (RR: 1.04, 95% CI [0.98, 1.10], P = 0.17). The incidence of bleeding did not differ between the DL and VL groups (RR: 0.59, 95% CI [0.32, 1.08], P = 0.09).Conclusions: Evidence as per this meta-analysis suggests VL leads to a shorter time to NTI, a greater first attempt success rate, and reduced need for maneuvers when compared to DL. The present study supports use of VL as a first line device for NTI in oral-maxillofacial surgeries in experienced hands.

Trial sequential analysis of a recently published study on video laryngoscopy vs. direct laryngoscopy for nasotracheal intubation in oro-maxillofacial surgery

“…Importantly, all the TSAs confirmed the robustness of the findings of Gupta et al [1] as the Z-curve of effect crossed the adjusted significance thresholds in all analyses.…”

“…We congratulate Gupta et al [1] for conducting a very interesting meta-analysis on the comparative characteristics of video laryngoscope (VL) compared to direct laryngoscope (DL) for nasotracheal intubation (NTI) in oro-maxillofacial surgeries.…”

“…The information size was computed assuming an alpha risk of 5% with a power of 80%. We used a random-effects model and for the estimated effects on the investigated outcomes, we used the mean difference reported by Gupta et al [ 1 ] for the continuous outcomes and RR reduction for dichotomous outcomes. Further details on TSAs and their interpretation are available elsewhere [ 2 , 3 ].…”

The utilization of video laryngoscopy in nasotracheal intubation for oral and maxillofacial surgical procedures: a narrative review

“…Although some studies indicate no overall difference in the success rate of intubation between VL and DL during NTI [ 13 45 ], a meta-analysis by Jiang et al reported that VL increases the first attempt success rate (relative risk (RR), 1.09; 95% CI, 1.00–1.17; n = 930; P = 0.04), especially in cases of difficult airways [ 45 ]. Park et al reported higher success rates on the first attempt in groups using VL than in those using DL (93.8% vs. 74.8%, P < 0.001) [ 56 ].…”

“…In the existing literature on the application of VL for NTI, the specific advantages in oral and maxillofacial surgical contexts have not been as extensively documented as those in other areas of surgical practice [ 12 13 ].…”