DL vs. VL
A 2023 NEJM article reports the results of a large (n=1417) multicenter RCT. The primary outcome was successful intubation on the first attempt. The secondary outcome was severe complications. 91.5% of patients were intubated by EM or ICU staff. The trial was stopped at the first pre-planned interim analysis because the primary outcome was met and showed superiority of VL over DL. There was no difference in secondary outcomes.
Is the primary outcome clinically relevant? Look at supplement pages 33 and 36, which shows that for providers who were experienced at DL there was no difference in the primary outcome. Experienced means >100 prior intubations with DL. Is there a scenario where DL is useful? If so, we should practice it since we need to be the best at intubating in challenging situations? Do DL skills atrophy once acquired if you stop practicing?
A 2026 JAMA open network article reported on a large pragmatic multi-center RCT with anesthesiologists assigned to use DL vs. VL. The primary outcome was first pass success, and they found a 4% (VLM) or 9% (VLH) absolute difference favoring video over DL. Secondary outcomes that were significant included faster time to intubation (4-6 seconds difference), easier self-described difficulty, less intermittent BMV required, switch in technique required.
A few thoughts on this study. Stylet use was much lower in the DL group--35% (DL) compared to 75% (VLM) or 96% (VLH) and this has been shown in other studies to influence first pass success rates. It was not stated whether residents were performing the intubations or attendings, but 5 of the 6 sites were academic centers, so potentially experience with DL was limited amongst some of the intubating staff if they were junior residents. They did state that all anesthesiologists had performed at least 25 VLs. Approximately 27,000 of the 29,000 patients screened were excluded, ~17,800 of which were ineligible, and ~8,500 of which they were understaffed to enroll. Exclusion criteria included pregnant patients, anticipated need for fiberoptic intubation, or anesthesiologist concerns about randomizing the laryngoscopy technique. There may have been some selection bias due to high exclusions of patients who were excluded based on the preference of the anesthesiologist.