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J Clin Anesth. 2019 Feb;52:6-16. doi: 10.1016/j.jclinane.2018.08.029. Epub 2018 Aug 25.

Videolaryngoscopy versus direct laryngoscopy for nasotracheal intubation: A systematic review and meta-analysis of randomised controlled trials.

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Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
Beijing Hospital of Traditional Chinese Medicine, affiliated with Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, China.
Department of Anesthesiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China. Electronic address:



Nasotracheal intubation (NTI) is a common practice in the oral and maxillofacial surgeries. A systematic review and meta-analysis was performed to determine whether videolaryngoscopy (VL) compared with direct laryngoscopy (DL) can lead to better outcomes for NTI in adult surgical patients.


Only randomised controlled trials comparing VL and DL for NTI were included. The primary outcome was overall success rate and the second outcomes were first-attempt success rate, intubation time, rate of Cormack and Lehane classification 1, rate of Magill Forceps used, rate of postoperative sore throat, and ease of intubation.


Fourteen studies with 20 comparisons (n = 1052) were included in quantitative synthesis. The overall success rate was similar between two groups (RR, 1.03; p = 0.14; moderate-quality evidence). VL was associated with a higher first-attempt success rate (RR 1.09; p = 0.04; low-quality evidence), a shorten intubation time (MD-6.72 s; p = 0.0001; low-quality evidence), a higher rate of Cormack and Lehane classification 1 (RR, 2.11; p < 0.01; high-quality evidence), a less use of the Magill forceps (RR, 0.11; p < 0.01; high-quality evidence) and a lower incidence of postoperative sore throat (RR, 0.50; p = 0.03; high-quality evidence). Subgroup analysis based on whether with a difficult airway showed higher overall success (p < 0.01) and first-attempt success rates with VL (p = 0.04) in patients with difficult airways; however, these benefits was not shown in patients with a normal airway (p > 0.05); Subgroup analysis based on operators' experience showed that success rate did not differ between groups (p > 0.05), but intubation time was shortened by more than 50s by non-experienced operators (p < 0.05). Subgroup analysis based on different devices used showed that only non-integrated VL led to a shorter intubation time (p < 0.05).


The use of VL does not increase the overall success rate of NTI in adult patients with general anesthesia, but it improves the first-attempt success rate and laryngeal visualization, and shortens the intubation time. VL is particularly beneficial for patients with difficult airways.


Airway management; Nasotracheal intubation; Videolaryngoscopy

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