Conventional vs Video-Assisted Laryngoscopy for Perioperative Endotracheal Intubations: A Randomized Clinical Trial

Area of Science:

• Anesthesiology
• Airway Management
• Surgical Innovation

Background:

• Video laryngoscopy is increasingly used for tracheal intubation, but its clinical outcomes and the role of hyperangulated blades remain unclear.
• Evidence comparing video laryngoscopy (VL) with direct laryngoscopy (DL) for routine intubations is inconclusive.

Purpose of the Study:

• To determine if video laryngoscopy, irrespective of blade type, offers superior first-pass success compared to direct laryngoscopy during routine tracheal intubations.
• To evaluate the efficacy of different video laryngoscope blade geometries.

Main Methods:

• A 3-arm randomized clinical trial (COVALENT) involving 2532 adult patients undergoing general anesthesia across 6 centers in Germany and Austria.
• Patients were randomized to direct laryngoscopy (DL), video laryngoscopy with a Macintosh blade (VLM), or video laryngoscopy with a hyperangulated blade (VLH).
• The primary outcome was the first-pass intubation success rate, with secondary outcomes including time to intubation and complications.

Main Results:

• Video laryngoscopy (VLM: 82.9%, VLH: 87.6%) demonstrated significantly higher first-pass intubation success rates compared to direct laryngoscopy (DL: 78.2%; P < .001).
• VL modalities resulted in faster intubation success after a failed first attempt and were associated with fewer complications like lip/dental injuries.
• Hyperangulated blades (VLH) showed a trend towards higher success rates than Macintosh blades (VLM).

Conclusions:

• Video laryngoscopy significantly enhances first-pass success rates for tracheal intubation in the operating room compared to direct laryngoscopy.
• The findings suggest video laryngoscopy should be considered a new standard of care for routine airway management.
• Both Macintosh and hyperangulated video laryngoscopes offer advantages over direct laryngoscopy.