Efficacy of video laryngoscopy versus direct laryngoscopy for critically Ill adults undergoing tracheal intubation: a trial sequential analysis and meta-analysis.
BMC anesthesiology · 2026-04-06 · Meta-analysis
Abstract
BACKGROUND: Previous meta-analyses have yielded conflicting conclusions about video laryngoscopy (VL) efficacy in critically ill adults, often including heterogeneous populations (e.g., trainees) or non-emergency settings. This study addresses a critical knowledge gap by focusing exclusively on experienced operators in emergency intubations. METHODS: We updated our systematic review to include 18 RCTs (5,097 patients) published up to January 2026, exceeding prior meta-analyses (e.g., 12 RCTs in 2025). Novel subgroup analyses explored settings (ICU/ED/prehospital) and neuromuscular blockade (NMBAs) use. Trial Sequential Analysis (TSA) was incorporated to assess evidence certainty. RESULTS: Video laryngoscopy (VL) was associated with a significantly higher first-attempt success rate compared to direct laryngoscopy (DL) (risk ratio [RR] = 1.09; 95% confidence interval [CI]: 1.01–1.17; p < 0.0001), with substantial heterogeneity (I² = 88%; 18 trials). The benefit appeared more pronounced in the ICU and ED settings. No significant differences were observed in intubation time (MD=-2.38, 95% CI [-5.86, 1.11]), mortality (RR=0.97, 95% CI [0.84, 1.11]), or hospital stay (MD=-0.17, 95% CI [-2.04, 1.71]). Subgroup analyses revealed greater VL efficacy with routine neuromuscular blockade use (RR = 1.11, P = 0.03) The trial sequential analysis indicated insufficient sample size for definitive conclusions. CONCLUSION: VL enhances first-pass success in experienced hands, especially in ICUs. Larger trials are needed to confirm broader applicability. This study advances prior work by focusing on high-acuity settings and rigorous methodologic standards. TRIAL REGISTRATION: This review is registered with PROSPERO ( http://www.crd.york.ac.uk/PROSPERO , CRD42023458066).
Tags
Endotracheal intubation · Muscle relaxants · Video laryngoscopy