Conventional vs Video-Assisted Laryngoscopy for Perioperative Endotracheal Intubations: A Randomized Clinical Trial.

Summary

In the multicenter COVALENT randomized trial, 2423 patients were analyzed after assignment to direct laryngoscopy, video laryngoscopy with a Macintosh blade, or hyperangulated video laryngoscopy. First-pass success was 78.2% with direct laryngoscopy, 82.9% with Macintosh video laryngoscopy, and 87.6% with hyperangulated video laryngoscopy; both video techniques were superior to direct laryngoscopy.

Key Findings

• First-pass success was 78.2% with direct laryngoscopy, 82.9% with Macintosh video laryngoscopy, and 87.6% with hyperangulated video laryngoscopy.
• Both video laryngoscopy approaches were statistically superior to direct laryngoscopy for first-pass success.
• After failed first attempts, video laryngoscopy achieved positive capnography faster than direct laryngoscopy, and hyperangulated devices had fewer reported lip or dental injuries and blood on the blade.

Clinical Implications

Routine operating-room intubation services should consider video laryngoscopy as the default first-line technique, while maintaining competency in direct laryngoscopy and selecting blade geometry according to operator expertise, patient anatomy, and equipment availability.

Limitations

• Pregnant patients, planned fiberoptic intubations, and patients requiring non-general anesthesia were excluded, limiting applicability to those populations.
• The study was not designed to determine superiority in difficult-airway or emergency settings, and operator experience may have influenced device-specific performance.

Future Directions

Future trials should evaluate video laryngoscopy in anticipated and unanticipated difficult airways, emergency intubation, obese and pregnant populations, and resource-limited settings, while examining training requirements, cost-effectiveness, and patient-centered complications.