Implementation of default videolaryngoscopy instead of direct laryngoscopy for tracheal intubation: a narrative review of evidence and experiences.

Introduction: Default videolaryngoscopy - use of a videolaryngoscope in preference to a direct laryngoscope - remains a hotly debated topic. High-risk tracheal intubations performed during the COVID-19 pandemic added to the extensive existing evidence of advantages of videolaryngoscopy for patients and staff. Despite this, and calls for implementation of default videolaryngoscopy, it has not been adopted widely.

Methods: We summarise current evidence for the benefits of videolaryngoscopy and discuss (and where appropriate dispute) the common reasons given for not using videolaryngoscopy. The experiences of five UK NHS hospitals which have made a move to default videolaryngoscopy are described, with practical advice to assist other hospitals planning similar projects.

Results: Several recent large randomised controlled trials and meta-analyses, incorporating data from over 200 trials, support the use of videolaryngoscopes. Guidelines and reports published since 2015 have recommended immediate access to videolaryngoscopes plus training and skill acquisition in the required techniques. Recent guidelines have recommended the routine use of videolaryngoscopes whenever possible. Reported advantages include: technical benefits (improved safety, efficacy and ease of tracheal intubation plus fewer complications); non-technical benefits (including improved teamwork and communication); improved direct laryngoscopy training; and environmental benefits. Reasons cited for not using a videolaryngoscope include concerns that they: are unnecessary; lead to decay in or failure to learn direct laryngoscopy skills; videolaryngoscopy failure; ineffectiveness in a soiled airway; cost; and challenges relating to decontamination of reusable blades. We discuss these and, where appropriate, provide counter arguments.

Discussion: This narrative review provides the relevant evidence and information for clinicians, managers, procurement teams and sterile services departments to use, should a business case be proposed to implement default videolaryngoscopy. We describe effective practical strategies for addressing implementation challenges.