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We appreciate the letter to the editor by Drs. Latif and Akca (1) regarding our recent Facilitating Endotracheal intubation by Laryngoscopy technique and apneic Oxygenation Within the ICU (FELLOW) trial of video laryngoscopy (VL) versus direct laryngoscopy (DL) for endotracheal intubation of critically ill adults (2).
Drs. Latif and Akca (1) raise the point of whether an experiment was performed in the FELLOW trial. In this trial, 98.6% of VL intubations were performed with the McGrath MAC video laryngoscope (Medtronic, Minneapolis, MN) and 94.7% of DL intubations were performed with curved blades. Despite an experiment having occurred in the FELLOW trial (VL group having significantly better glottic visualization), Drs. Latif and Akca (1) argue that glottic visualization is not as meaningful regarding increased procedural success as the angulation of the VL blade. Unfortunately, supposition that the angle of the blade rather than glottic view is the truly meaningful intervention is only speculative, and this assertion differs from the fundamental argument in favor of VL expressed by experts, specifically that VL provides a superior view of the glottis (3). In addition, the existing data from randomized trials of devices with hyperangulated blades mentioned by Drs. Latif and Akca (1) all show that these hyperangulated blades do not improve success (4) or may even be harmful (5). Finally, Drs. Latif and Akca (1) cite a previous study (6) using GlideScope as the only VL device as evidence that hyperangulated blades may be superior to direct laryngoscopes with curved blades. We would point out that the conclusion of the study’s authors was that the differences between VL and DL were related to differences in glottic view with no mention of blade angle and that the large effect size seen in this previous study was likely due to a lack of randomization and no use of neuromuscular blockade.
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