Effect of hyperangulated videolaryngoscopy on first-attempt success in tracheal intubations: A systematic review and...

To determine whether hyperangulated videolaryngoscopy (HAVL) improves first-attempt success (FAS) in adult orotracheal intubations compared to standard-geometry videolaryngoscopy (SGVL), with a focus on emergency settings.

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and comparative observational studies evaluating HAVL versus SGVL in adult tracheal intubations. Comprehensive searches were performed in Ovid MEDLINE, Embase, Cochrane, Scopus, and web of science from inception through November 2024. Risk of bias was assessed using RoB2 and Newcastle-Ottawa tools, and certainty of evidence was rated using GRADE. Both emergency and operating room intubations were included; most emergency data derived from large cohort studies.

Of 4445 screened records, 25 studies (17 RCTs, 8 observational; 38,597 patients) were included. HAVL was associated with lower FAS overall (87.2 % vs 91.0 %; pooled RR 0.96, 95 % CI 0.94-0.99; p = 0.002). In emergency intubations (8 studies; n = 34,927), HAVL yielded reduced FAS (RR 0.97, 95 % CI 0.95-0.99; p = 0.003). There was no significant difference in difficult airways (RR 0.98, 95 % CI 0.92-1.05; p = 0.57). HAVL was linked to higher rates of airway trauma (7.5 % vs 2.9 %; RR 1.88, 95 % CI 1.01-3.49; p = 0.046) and numerically more adverse events. Certainty of evidence was low due to risk of bias and heterogeneity.

In emergency intubations, HAVL was associated with lower first-attempt success and increased airway trauma compared to SGVL. These findings support prioritizing SGVL for emergency airway management, with careful operator training if HAVL is used.