Comparative Effectiveness of Video and Direct Laryngoscopy on First-Pass Success andPeri-intubation Events

Abstract

Background:
First-pass success during tracheal intubation is critical for reducing peri-intubation complications, especially in emergency and critical care settings. Video laryngoscopy may offer advantages over direct laryngoscopy in improving glottic visualization and intubation outcomes.
Methods
This systematic review included studies comparing video and direct laryngoscopy in adult patients undergoing tracheal intubation in operating rooms, emergency departments, or intensive care units. A comprehensive PubMed search (inception-July 2025) identified randomized clinical trials and cohort studies reporting first-pass success and related outcomes.
Results
Eight studies (five randomized trials, three cohorts; n = 8,700) met inclusion criteria. First-pass success rates ranged from 61.9% to 98.3% for video laryngoscopy and 59% to 96.2% for direct laryngoscopy. Four studies reported significantly higher success with video (e.g., 85.1% vs 70.8%; risk difference 14.3%, 95% CI 9.9-18.7). Two studies showed no difference, and one favored direct laryngoscopy in a prehospital setting. Video laryngoscopy reduced esophageal intubation (RR 0.44, 95% CI 0.24-0.80) and aspiration risk (RR 0.63, 95% CI 0.41-0.96), with similar rates of hypoxemia and hypotension. Time to intubation was marginally longer with video but not clinically significant.
Conclusions
Video laryngoscopy improves first-pass success and reduces airway-related complications compared to direct laryngoscopy in most adult emergency and perioperative intubations. Operator training and setting influence effectiveness.