Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.

We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I² statistics. All outcomes were submitted to random-effect models.

Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04–1.20; p < 0.01; I² = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24–0.80; p < 0.01; I² = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41–0.96; p = 0.03; I² = 0%) compared to DL.

VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients.

Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685. Registered 6 July 2023.