Scope and Framing This review examines whether videolaryngoscopy (VL) should replace direct laryngoscopy (DL) as the default first-line approach for tracheal intubation, with emphasis on the operating room setting and implications for trainee education. The evidence landscape has shifted dramatically since 2022, driven by several large RCTs, updated Cochrane meta- analyses, and new society guidelines — most notably…
THE EVIDENCE
What each source contributes, and how strong it is
Study design first — a cohort and a randomised trial do not carry the same weight.
Design
Year
Journal
What it found
Guideline
2025
European journal of anaesthesiolog
The multidisciplinary recommendations for universal videolaryngoscopy rest on 12
Macintosh-style videolaryngoscopy probably reduces failed intubation rates compared to direct laryngoscopy (RR 0.41, 95% CI 0.26 to 0.65).
British journal of anaesthesia 2022
Videolaryngoscopes of every design reduce failed intubation, improve first-attempt
Videolaryngoscopes of every design reduce failed intubation, improve first-attempt success and glottic view
WHERE THE GUIDANCE SITS
The multidisciplinary recommendations for universal videolaryngoscopy rest on 12
Guideline · European journal of anaesthesiolog
The multidisciplinary recommendations for universal videolaryngoscopy rest on 12 statements that were mostly formulated from expert opinion, because the quality of available evidence was low.
Guidelines on Strategies for the Universal Implementation of Videolaryngoscopy, European journal of anaesthesiology 2025 · PMID 40534455
Meta-analysis · The Cochrane database of systemati
Macintosh-style videolaryngoscopy probably reduces failed intubation rates compared to direct laryngoscopy (RR 0.41, 95% CI 0.26 to 0.65).
Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation, The Cochrane database of systematic reviews 2022 · PMID 35373840
WHERE THE GUIDANCE SITS
Videolaryngoscopes of every design reduce failed intubation, improve first-attempt
Meta-analysis · British journal of anaesthesia
Videolaryngoscopes of every design reduce failed intubation, improve first-attempt success and glottic view, and hyperangulated designs are the ones that reduce oesophageal intubation and help most in patients with difficult airway features.
Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation: A Cochrane Systematic Review and Meta-Analysis Update, British journal of anaesthesia 2022 · PMID 35820934
WHAT THE TRIALS FOUND
Where randomised evidence moved the question
2 findings, each on the slide that follows.
JAMA 2024
Starting with a hyperangulated videolaryngoscope cut the need for more than one
Starting with a hyperangulated videolaryngoscope cut the need for more than one intubation attempt from 7.6% to 1.7% and intubation failure from 4.0%…
Anaesthesia 2023
In patients with no predicted difficult airway, first-pass success was 94% with a
In patients with no predicted difficult airway, first-pass success was 94% with a Macintosh-bladed videolaryngoscope versus 82% with direct…
WHAT THE TRIALS FOUND
Starting with a hyperangulated videolaryngoscope cut the need for more than one
Randomised trial · JAMA
Starting with a hyperangulated videolaryngoscope cut the need for more than one intubation attempt from 7.6% to 1.7% and intubation failure from 4.0% to 0.27%, with no difference in airway or dental injury.
Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room, JAMA 2024 · PMID 38497992
Fewer attempts and far fewer failures, with no increase in airway or dental injury.
Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room, JAMA 2024 · PMID 38497992
WHAT THE TRIALS FOUND
In patients with no predicted difficult airway, first-pass success was 94% with a
Randomised trial · Anaesthesia
In patients with no predicted difficult airway, first-pass success was 94% with a Macintosh-bladed videolaryngoscope versus 82% with direct laryngoscopy, and a Cormack-Lehane grade of 3 or worse fell from 8% to 0.7%.
A Multicentre Randomised Controlled Trial of the McGrath™ Mac Videolaryngoscope Versus Conventional Laryngoscopy, Anaesthesia 2023 · PMID 36928625
THE NUMBERS
First-pass success in patients with no predicted difficulty
2,092 elective intubations, McGrath Macintosh blade.
The benefit is not confined to the difficult airway — it shows up in routine cases.
A Multicentre Randomised Controlled Trial of the McGrath™ Mac Videolaryngoscope Versus Conventional Laryngoscopy, Anaesthesia 2023 · PMID 36928625
IN PRACTICE
Guidelines now recommend routine videolaryngoscopy where possible
Review · Anaesthesia
Guidelines now recommend routine videolaryngoscopy where possible, and the objections that need answering are practical ones — decay of direct laryngoscopy skills, cost, and decontamination of reusable blades.
Implementation of Default Videolaryngoscopy Instead of Direct Laryngoscopy for Tracheal Intubation: A Narrative Review of Evidence and Experiences, Anaesthesia 2025 · PMID 40842319
THE NUMBERS
For rapid sequence intubation the gap is wider still
1,000 patients randomised in theatre.
94% versus 72% first-pass, with adverse events falling from 12.2% to 2.6%.
INDICATIONS
When this is the right block
Cochrane review, videolaryngoscopy versus direct laryngoscopy, 2022
Routine adult tracheal intubation
Across 222 studies and 26,149 participants, videolaryngoscopes of all designs likely reduced failed intubation and produced higher rates of first-attempt success with improved glottic views; Macintosh-style devices reduced failed intubation with a risk ratio of 0.41 and hypoxaemia with a risk ratio of 0.72 on moderate-certainty evidence.
Cochrane review, videolaryngoscopy versus direct laryngoscopy, 2022
Known or predicted difficult airway
Hyperangulated videolaryngoscopes reduced failed intubation with a risk ratio of 0.51 overall, and in subgroup analysis the effect was stronger in known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48). They also reduced oesophageal intubation (RR 0.39).
DEVICE trial, video versus direct laryngoscopy, N Engl J Med 2023
Critically ill adults in the emergency department or ICU
In the DEVICE trial, 1417 critically ill adults were randomised and first-attempt success was 85.1% with a video laryngoscope versus 70.8% with a direct laryngoscope, an absolute risk difference of 14.3 percentage points. The trial was stopped for efficacy at its single preplanned interim analysis.
DEVICE trial, video versus direct laryngoscopy, N Engl J Med 2023
Intubations performed by trainees
In DEVICE, 91.5% of intubations were performed by an emergency medicine resident or a critical care fellow, and the first-attempt advantage held in that population.
CONTRAINDICATIONS
When it is not
DEVICE trial, video versus direct laryngoscopy, N Engl J Med 2023
Expecting it to fix the patient's physiology
In DEVICE, severe complications during intubation — severe hypoxaemia, severe hypotension, new or increased vasopressor use, cardiac arrest or death — occurred in 21.4% of the video group and 20.9% of the direct group, an absolute difference of 0.5 percentage points. A better view does not resuscitate anyone.
Cochrane review, videolaryngoscopy versus direct laryngoscopy, 2022
Assuming a hyperangulated blade solves oxygenation
Macintosh-style and channelled videolaryngoscopes likely reduced hypoxaemic events (RR 0.72 and 0.25), but hyperangulated devices showed no clear difference in hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11) on low-certainty evidence. The view improves faster than the tube delivery does.
Declining incidence of awake tracheal intubation, Can J Anaesth 2023
Substituting it for an awake technique when severe difficulty is predicted
Awake tracheal intubation is what guidelines recommend when significant difficulty is predicted, and in a 692-case cohort awake first-attempt success was 60% with videolaryngoscopy against 84% with flexible bronchoscopy. A screen does not convert an anticipated difficult airway into an asleep one.
PEARLS
What experience adds
Cochrane review, videolaryngoscopy versus direct laryngoscopy, 2022
Nobody knows whether it is faster
The Cochrane review could not pool time to tracheal intubation for any device class because of considerable heterogeneity (I² of 96%, 99% and 98% for Macintosh-style, hyperangulated and channelled devices). Speed is the claim the evidence does not support.
DEVICE trial, video versus direct laryngoscopy, N Engl J Med 2023
The critical-illness evidence is one trial, stopped early
DEVICE was a 17-site randomised trial that met its primary endpoint and was stopped for efficacy at the single preplanned interim analysis, with safety outcomes including oesophageal intubation, dental injury and aspiration similar between groups.
Eyes in the mouth first, then on the screen
Get the blade past the teeth and to the vallecula while looking at the patient, then move your eyes up. Watching the monitor from the moment the blade leaves your hand is how lips get caught and how you lose the sense of how much room you actually have.
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
The multidisciplinary recommendations for universal videolaryngoscopy rest on 12 statements that were mostly formulated from expert opinion, because the quality of available evidence was low.
2
2
Macintosh-style videolaryngoscopy probably reduces failed intubation rates compared to direct laryngoscopy (RR 0.41, 95% CI 0.26 to 0.65).
3
3
Videolaryngoscopes of every design reduce failed intubation, improve first-attempt success and glottic view, and hyperangulated designs are the ones that reduce oesophageal intubation and help most in patients with difficult airway features.
4
4
Starting with a hyperangulated videolaryngoscope cut the need for more than one intubation attempt from 7.6% to 1.7% and intubation failure from 4.0% to 0.27%, with no difference in airway or dental injury.
5
5
In patients with no predicted difficult airway, first-pass success was 94% with a Macintosh-bladed videolaryngoscope versus 82% with direct laryngoscopy, and a Cormack-Lehane grade of 3 or worse fell from 8% to 0.7%.
The oral-boards stem on the next slide puts these into one scenario.
KEY TAKEAWAYS
What to carry into the next case
The multidisciplinary recommendations for universal videolaryngoscopy rest on 12
Starting with a hyperangulated videolaryngoscope cut the need for more than one
JAMA 2024
Guidelines now recommend routine videolaryngoscopy where possible
Anaesthesia 2025
The multidisciplinary recommendations for universal videolaryngoscopy rest on 12
Questions I'll ask you in the room
Walk me through your setup for this before we start.
What are you watching on the monitor that would tell you this is going wrong?
What is your first move if it does?
What would you want ready in the room before induction?
Oral boards stem
You are supervising a CA-1 for a routine laparoscopic appendicectomy in a patient with no predictors of a difficult airway. The resident reaches for a Macintosh blade and you ask why not the videolaryngoscope.
Board questions
1. In the operating-room randomised comparison of starting with a hyperangulated videolaryngoscope versus direct laryngoscopy, give the rate of needing more than one intubation attempt and the rate of intubation failure in each group, and state what was found for airway and dental injury.
Show answer
Starting with a hyperangulated videolaryngoscope cut the need for more than one attempt from 7.6% to 1.7% and intubation failure from 4.0% to 0.27%, with no difference in airway or dental injury.
Fewer attempts and fewer failures, and no difference in airway or dental injury — that is the case for reaching for the hyperangulated scope first.
Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room, JAMA 2024 · PMID 38497992
2. In a multicentre randomised trial restricted to patients with no predicted difficult airway, compare first-pass intubation success and the incidence of a Cormack-Lehane grade of 3 or worse between a Macintosh-bladed videolaryngoscope and conventional direct laryngoscopy.
Show answer
First-pass success was 94% with the Macintosh-bladed videolaryngoscope versus 82% with direct laryngoscopy, and a Cormack-Lehane grade of 3 or worse fell from 8% to 0.7%.
Even in airways with no predicted difficulty, the Macintosh-bladed videolaryngoscope gave a better view and a higher first-pass success rate.
A Multicentre Randomised Controlled Trial of the McGrath™ Mac Videolaryngoscope Versus Conventional Laryngoscopy, Anaesthesia 2023 · PMID 36928625
3. Summarise what videolaryngoscopes of every design achieve compared with direct laryngoscopy, and state specifically what the hyperangulated designs add.
Show answer
Videolaryngoscopes of every design reduce failed intubation and improve first-attempt success and glottic view; the hyperangulated designs are the ones that reduce oesophageal intubation and that help most in patients with difficult airway features.
Every design improves the view and first-attempt success, but reducing oesophageal intubation and helping most with difficult airway features is specific to the hyperangulated blades.
Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation: A Cochrane Systematic Review and Meta-Analysis Update, British journal of anaesthesia 2022 · PMID 35820934
4. Multidisciplinary recommendations advise universal videolaryngoscopy. How many statements do they contain, what were those statements mostly formulated from, why was that, and how strongly can you therefore cite them?
Show answer
The recommendations rest on 12 statements that were mostly formulated from expert opinion, because the quality of the available evidence was low; they should therefore be cited as consensus expert opinion rather than as high-quality evidence.
Twelve statements built mostly from expert opinion because the evidence quality was low — quote them as consensus, not as proof.
Guidelines on Strategies for the Universal Implementation of Videolaryngoscopy, European journal of anaesthesiology 2025 · PMID 40534455
The bottom lineThe multidisciplinary recommendations for universal videolaryngoscopy rest on 12
Sources
[1] Guidelines on Strategies for the Universal Implementation of Videolaryngoscopy, European journal of anaesthesiology 2025 · PMID 40534455 open
[2] Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation, The Cochrane database of systematic reviews 2022 · PMID 35373840 open
[3] Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room, JAMA 2024 · PMID 38497992 open
[4] Implementation of Default Videolaryngoscopy Instead of Direct Laryngoscopy for Tracheal Intubation: A Narrative Review of Evidence and Experiences, Anaesthesia 2025 · PMID 40842319 open
[5] Videolaryngoscopy Versus Direct Laryngoscopy for Adults Undergoing Tracheal Intubation: A Cochrane Systematic Review and Meta-Analysis Update, British journal of anaesthesia 2022 · PMID 35820934 open
[6] A Multicentre Randomised Controlled Trial of the McGrath™ Mac Videolaryngoscope Versus Conventional Laryngoscopy, Anaesthesia 2023 · PMID 36928625 open
[7] DEVICE trial, video versus direct laryngoscopy, N Engl J Med 2023 · PMID 37326325 open
[8] Declining incidence of awake tracheal intubation, Can J Anaesth 2023 · PMID 36289151 open