Videolaryngoscopy vs. direct laryngoscopy in class 2 and 3 obesity: a systematic review, meta-analysis and trial sequential analysis of randomised controlled trials.

Summary

Across 10 RCTs (n=955) in class 2–3 obesity, videolaryngoscopy markedly reduced failed tracheal intubation (RR 0.15), hypoxemia (RR 0.21), and first-attempt failure (RR 0.44), with better glottic views and no meaningful increase in intubation time or sore throat.

Key Findings

• Failed tracheal intubation reduced with videolaryngoscopy (RR 0.15 [0.05–0.35], p<0.001; nine studies).
• Hypoxemia reduced (RR 0.21 [0.10–0.43], p<0.001; seven studies) and first-attempt failure reduced (RR 0.44 [0.25–0.76], p=0.004).
• Improved glottic visualization without significant differences in intubation time, sore throat, or intubation difficulty scale.

Clinical Implications

Adopt videolaryngoscopy as first-line for intubation in class 2–3 obesity to reduce hypoxemia and failed attempts; ensure training and device availability.

Limitations

• Heterogeneity in videolaryngoscope models and operator experience across trials
• Predominantly elective general surgery; applicability to emergent airways or ICU may differ

Future Directions

Head-to-head comparisons of videolaryngoscope types in severe obesity, evaluation in emergency/ICU settings, and cost-effectiveness analyses.