ALS 3308 Tracheal Intubation using Video Laryngoscopy as Compared to Direct laryngoscopy During Cardiopulmonary Resuscitation TF SR

Conflict of Interest Declaration

• Ari Moskowitz: Funding from the US National Heart, Lung, and Blood Institute for a randomized trial of supraglottic airways vs. tracheal intubation during cardiac arrest.

CoSTR Citation

Ari Moskowitz; Jerry P Nolan; Conor Crowley; Jasmeet Soar; Sabine Nabecker; Markus B Skrifvars; Daniel Fein; Matthew Prekker; Katherine Berg; Marie Elias; Carolyn M Zelop; Ian Drennan; for the ILCOR Advanced Life Support Task Force. Tracheal Intubation using Video Laryngoscopy as Compared to Direct Laryngoscopy During Cardiac Arrest Resuscitation. Consensus on Science with Treatment Recommendations: International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force, 2026. Available from: http://ilcor.org

Methodological Preamble and Link to Published Systematic Review

The continuous evidence evaluation process for the production of Consensus on Science with Treatment Recommendations (CoSTR) started with a systematic review of video vs. direct laryngoscopy during adult cardiac arrest (PROSPERO: CRD420251083717) conducted by a systematic review team with involvement of clinical content experts from the ILCOR ALS Task Force in addition to content area experts from outside of the ILCOR group. Results of the systematic review were discussed by the ALS Task Force and treatment recommendations were generated.

Systematic Review

Submission Pending

PICOST

Consensus on Science

A total of 13,031 studies were identified in the initial search. After review, a total of 16 studies (3 RCTs and 13 observational studies were included in the analysis). Across all studies there was substantial variability in setting, device used for video laryngoscopy, person performing tracheal intubation, and outcomes studied. Risk of bias was similar for all outcomes in all cases, and thus each study received only a single risk of bias assessment. Overall certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology.

RCTs and non-randomized observational studies were considered separately during data synthesis. For randomized control trials, relevant outcomes were abstracted as above and a meta-analysis performed. As the RCTs varied in location, devices used, and persons performing tracheal intubation, a random-effects meta-analysis was performed. The observational studies reviewed were all judged to be at critical risk of bias. As such, no pooled estimates were obtained and instead data visualization techniques using forest plots were used. The Synthesis Without Meta-Analysis (SWiM) guidance was used in the generation of narrative summaries.¹

First Pass Tracheal Intubation Success (critical):

Very low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision) from three RCTs enrolling 331 patients showed no benefit video laryngoscopy as compared with direct laryngoscopy for tracheal intubation during cardiac arrest (Risk Ratio [RR] 0.88, 95% CI 0.63 – 1.22; 94 fewer patients/1000 had first pass success with the intervention, 95% CI 289 fewer to 172 more patients/1000).^2-4

Very low-certainty evidence (downgraded for risk of bias and indirectness) from twelve observational studies including 29,595 patients generally favoured video laryngoscopy as compared with direct laryngoscopy for tracheal intubation during cardiac arrest.^2,5-15 Of the twelve studies, eight (66.7%) had risk ratios favouring video laryngoscopy with 95% confidence intervals that did not cross 1.0.^{2,5,9-11,13-15} Point estimates in three of the remaining studies favoured video laryngoscopy, however the 95% confidence interval crossed 1.0. A single study of 97 patients had a point estimate favouring laryngoscopy without video-capability.⁷

Overall Tracheal Intubation Success (critical):

Very low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision) from three RCTs enrolling 331 patients showed no benefit of video laryngoscopy as compared with direct laryngoscopy for tracheal intubation during cardiac arrest (RR 1.0 95% CI 0.90 – 1.12; 0 difference in the number of intubation successes between groups, 95% CI 90 fewer to 90 more patients/1000). Results were similar in the fixed-effect sensitivity analysis.^2-4

Very low-certainty evidence (downgraded for risk of bias and indirectness) from six observational studies including 24,964 patients generally favoured video laryngoscopy as compared with direct laryngoscopy for tracheal intubation during cardiac arrest.^{7,10-12,14,15} Of the six studies, five (83.3%) had risk ratios favouring video laryngoscopy with 95% confidence intervals that did not cross 1.0. The point estimate of the remaining study favoured video laryngoscopy.^10-12,14,15

Return of Spontaneous Circulation (critical):

No randomized trials include the outcome of ROSC. Very low-certainty evidence (downgraded for risk of bias and indirectness) from six observational studies including 38,466 patients generally showed no between-group difference in rate of ROSC.^{6,8,10,12,14,16} All included studies had a risk ratio of 1.0 in the 95% confidence interval and point estimates were mixed above and below a risk ratio of 1.0.

Short-term Survival (hospital discharge or 30-days; critical):

No randomized trials included the outcome of short-term survival. Very low-certainty evidence (downgraded for risk of bias and indirectness) from three observational studies including 15,073 patients showed point estimates all favouring video laryngoscopy. One large observational study found that video laryngoscopy was associated with survival (RR 1.14, 95%CI 1.02, 1.28)¹⁶, while two smaller observational studies had 95% confidence intervals that crossed 1.0^8,13.

Survival with Favorable Neurologic Outcome (critical):

No randomized trials included the outcome of survival with favorable neurologic outcome. Very low-certainty evidence (downgraded for risk of bias and indirectness) from two observational studies including 14,879 patients showed point estimates favouring video laryngoscopy. Both studies defined survival with good neurologic outcome as survival with a Cerebral Performance Score of 1 or 2. One large observational study found that video laryngoscopy was associated with survival with good neurologic outcome (RR 1.27, 95%CI 1.11, 1.45)¹⁶, while a smaller observational study found no association (RR 1.06, 95%CI 0.35, 3.22)¹⁰.

Esophageal Intubation (important):

Very low-certainty evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision) from one randomized trial including 140 patients found a lower rate of the outcome of esophageal intubation with video laryngoscopy. In that study, the rate of esophageal intubation was 4.3% among patients randomized to direct laryngoscopy and 0.0% in patients randomized to video laryngoscopy.¹⁷

Very low-certainty evidence downgraded for risk of bias and indirectness from five observational studies including 6,178 patients found a 5.6% esophageal intubation rate when performing direct laryngoscopy and 1.4% when using video laryngoscopy. All observational studies found a significant benefit with video laryngoscopy for this outcome.^2,5,8,10,15

Other Outcomes:

In two randomized trials, there was no significant difference in time to intubation comparing video laryngoscopy and direct laryngoscopy.^4,17 Among five observational studies examining time to intubation, times were faster with video laryngoscopy in two—including one substudy of a randomized trial where laryngoscopy time was robustly captured.^2,13

Good intubation view (generally defined as a Cormack-Lehane Grade 1 view), was more common with video-enabled laryngoscopy in all studies reporting this metric, including 1 randomized trial and 4 observational studies.^3,5,7,8,13

In one randomized trial, there were fewer chest compression interruptions when a video-enabled laryngoscope was used.¹⁷

Treatment Recommendations

• There is insufficient evidence to recommend video laryngoscopy in preference to direct laryngoscopy for tracheal intubation during cardiopulmonary resuscitation (weak recommendation, very-low certainty of evidence)

• To improve tracheal intubation first pass success, overall success, and to reduce rates of inadvertent esophageal intubation, it may be reasonable to select video laryngoscopy during cardiopulmonary resuscitation in settings where this equipment is available and the person performing tracheal intubation is well trained in the use of the device. (Good Practice Statement)

Justification and Evidence to Decision Framework Highlights

• This topic was prioritized by the Advanced Life Support Task Force given the expanded use of video-capable laryngoscopes in cardiac arrest and other emergency airway management settings.
• Existing Consensus on Science and Treatment Recommendations for Advanced Airway Management During Adult Cardiac Arrest do not differentiate between video and direct laryngoscopy.
• Airway management during cardiac arrest is uniquely challenging as a result of ongoing chest compressions, airway contamination, and restricted positioning, which may either enhance or diminish any performance advantages of video laryngoscopy.
• Prior systematic reviews and meta-analyses conducted by ILCOR have not found a benefit of tracheal intubation during cardiopulmonary resuscitation when compared to either bag-valve mask ventilation alone or supraglottic airway.¹⁸ Given this, it may be unlikely that one approach to tracheal intubation would result in improved patient-important outcomes as compared to another.
• The Advanced Life Support Task Force included both randomized and non-randomized studies, recognizing that existing randomized trials remain few, small, and have numerous methodological flaws while non-randomized data provide important real-world information despite a very high risk of bias.
• Across included studies, there was substantial heterogeneity in video-capable laryngoscope device type, persons performing tracheal intubation, and arrest setting (OHCA vs IHCA), which were considered by the task force in arriving at treatment recommendations. No study directly compared one make or model of video-capable laryngoscopy to another.
• In addition to studies of tracheal intubation during cardiopulmonary resuscitation, the Task Force is aware of indirect evidence comparing video laryngoscopy to direct laryngoscopy among patients not in cardiac arrest in the operating room and in non-elective and emergent tracheal intubations outside of the operating room. The indirect evidence considered generally matched findings from the cardiac arrest population, with a higher rate of first pass success and overall tracheal intubation success but no clear benefit in relation to patient-important outcomes such as hospital or longer-term functional survival. In a Cochrane Review that included six randomized trials comparing video laryngoscopy to direct laryngoscopy in prehospital settings (including two in cardiac arrest populations Arima 2014 & Ducharme 2017), there was no benefit of video as compared to direct laryngoscopy.¹⁹
• No data was identified from cardiac arrest populations regarding the cost-effectiveness of video laryngoscopy. Indirect evidence from tracheal intubation in the operating theatre suggest that video-laryngoscopy is cost effective.
• The Task Force noted potential procedural advantages (e.g., higher first-pass success, reduced esophageal intubation) when using a video-capable laryngoscope although these advantages do not currently translate into improved rates of ROSC, survival, or survival with good neurologic outcomes.
• The recommendation that there is insufficient evidence to recommend video laryngoscopy in preference to direct laryngoscopy in cardiopulmonary resuscitation was arrived at by consensus of the Advanced Life Support Task Force, based upon mixed data when assessing proximal and procedural outcomes favoring video laryngoscopy and no benefit to either approach when assessing more patient-important outcomes such as survival or survival with favorable neurologic outcome.
• The Task Force considered that in the absence of evidence supporting a different approach to tracheal intubation in the cardiac arrest population as compared to standard practice in non-elective tracheal intubation settings, it would be reasonable for persons performing tracheal intubation to proceed with their standard approach to laryngoscopy during cardiopulmonary resuscitation.

EtD: ALS 3308 Et D table

Knowledge Gaps

• There were no studies directly comparing different types of video-capable laryngoscopes, including no comparisons of hyperangulated vs. standard geometry laryngoscope blades.
• There were limited studies directly assessing whether the impact of video laryngoscopy was different based upon the experience and skillset of the person performing tracheal intubation.
• The cost effectiveness of a switch to video-capable laryngoscopes is unknown. This is especially true for the pre-hospital setting and in low-resource settings.
• There was no study exploring tracheal intubation adjuncts (e.g. gum elastic bougie/tube introducer) as they related to video vs. direct laryngoscopy.
• The training and experience requirements for each tracheal intubation laryngoscopic approach is uncertain.
• Evidence is limited regarding whether laryngoscopy practices and their associated outcomes differ based on etiology, initial arrest rhythm, or other patient-specific factors (e.g. obesity, pregnancy) during cardiac arrest.

References

1. Campbell M, McKenzie JE, Sowden A, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ. 2020;368:l6890.

2. Park SO, Kim JW, Na JH, et al. Video laryngoscopy improves the first-attempt success in endotracheal intubation during cardiopulmonary resuscitation among novice physicians. Resuscitation. 2015;89:188-194.

3. Ducharme S, Kramer B, Gelbart D, Colleran C, Risavi B, Carlson JN. A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation. Resuscitation. 2017;114:121-126.

4. Arima T, Nagata O, Miura T, et al. Comparative analysis of airway scope and Macintosh laryngoscope for intubation primarily for cardiac arrest in prehospital setting. The American Journal of Emergency Medicine. 2014;32(1):40-43.

5. Okamoto H, Goto T, Wong ZSY, Hagiwara Y, Watase H, Hasegawa K. Comparison of video laryngoscopy versus direct laryngoscopy for intubation in emergency department patients with cardiac arrest: A multicentre study. Resuscitation. 2019;136:70-77.

6. Jarman AF, Hopkins CL, Hansen JN, Brown JR, Burk C, Youngquist ST. Advanced Airway Type and Its Association with Chest Compression Interruptions During Out-of-Hospital Cardiac Arrest Resuscitation Attempts. Prehospital Emergency Care. 2017;21(5):628-635.

7. Risse J, Volberg C, Kratz T, et al. Comparison of videolaryngoscopy and direct laryngoscopy by German paramedics during out-of-hospital cardiopulmonary resuscitation; an observational prospective study. BMC Emergency Medicine. 2020;20(1):22.

8. Min BC, Park JE, Lee GT, et al. C-MAC Video Laryngoscope versus Conventional Direct Laryngoscopy for Endotracheal Intubation During Cardiopulmonary Resuscitation. Medicina. 2019;55(6):225.

9. Lee DH, Han M, An JY, et al. Video laryngoscopy versus direct laryngoscopy for tracheal intubation during in-hospital cardiopulmonary resuscitation. Resuscitation. 2015;89:195-199.

10. Santou N, Ueta H, Nakagawa K, et al. A comparative study of Video laryngoscope vs Macintosh laryngoscope for prehospital tracheal intubation in Hiroshima, Japan. Resuscitation Plus. 2023;13:100340.

11. Jarvis JL, McClure SF, Johns D. EMS Intubation Improves with King Vision Video Laryngoscopy. Prehospital Emergency Care. 2015;19(4):482-489.

12. Breeman W, Van Vledder MG, Verhofstad MHJ, Visser A, Van Lieshout EMM. First attempt success of video versus direct laryngoscopy for endotracheal intubation by ambulance nurses: a prospective observational study. European Journal of Trauma and Emergency Surgery. 2020;46(5):1039-1045.

13. Muhs AL, Seitz KP, Qian ET, et al. Video vs Direct Laryngoscopy for Tracheal Intubation After Cardiac Arrest: A Secondary Analysis of the Direct vs Video Laryngoscope Trial. Chest. 2025;167(5):1408-1415.

14. Huebinger RM, Stilgenbauer H, Jarvis JL, Ostermayer DG, Schulz K, Wang HE. Video laryngoscopy for out of hospital cardiac arrest. Resuscitation. 2021;162:143-148.

15. Maissan I, van Lieshout E, de Jong T, et al. The impact of video laryngoscopy on the first-pass success rate of prehospital endotracheal intubation in The Netherlands: a retrospective observational study. European Journal of Trauma and Emergency Surgery. 2022;48(5):4205-4213.

16. Risse J, Fischer M, Meggiolaro KM, et al. Effect of video laryngoscopy for non-trauma out-of-hospital cardiac arrest on clinical outcome: A registry-based analysis. Resuscitation. 2023;185.

17. Kim JW, Park SO, Lee KR, et al. Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators. Resuscitation. 2016;105:196-202.

18. Granfeldt A, Avis SR, Nicholson TC, et al. Advanced airway management during adult cardiac arrest: A systematic review. Resuscitation. 2019;139:133-143.

19. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation: a Cochrane systematic review and meta-analysis update. Br J Anaesth. 2022;129(4):612-623.