Efficacy of video laryngoscopy versus direct laryngoscopy for critically Ill adults undergoing tracheal intubation: a trial sequential analysis and meta-analysis

Previous meta-analyses have yielded conflicting conclusions about video laryngoscopy (VL) efficacy in critically ill adults, often including heterogeneous populations (e.g., trainees) or non-emergency settings. This study addresses a critical knowledge gap by focusing exclusively on experienced operators in emergency intubations. We updated our systematic review to include 18 RCTs (5,097 patients) published up to January 2026, exceeding prior meta-analyses (e.g., 12 RCTs in 2025). Novel subgroup analyses explored settings (ICU/ED/prehospital) and neuromuscular blockade (NMBAs) use. Trial Sequential Analysis (TSA) was incorporated to assess evidence certainty. Video laryngoscopy (VL) was associated with a significantly higher first-attempt success rate compared to direct laryngoscopy (DL) (risk ratio [RR] = 1.09; 95% confidence interval [CI]: 1.01–1.17; p < 0.0001), with substantial heterogeneity (I² = 88%; 18 trials). The benefit appeared more pronounced in the ICU and ED settings. No significant differences were observed in intubation time (MD=-2.38, 95% CI [-5.86, 1.11]), mortality (RR=0.97, 95% CI [0.84, 1.11]), or hospital stay (MD=-0.17, 95% CI [-2.04, 1.71]). Subgroup analyses revealed greater VL efficacy with routine neuromuscular blockade use (RR = 1.11, P = 0.03) The trial sequential analysis indicated insufficient sample size for definitive conclusions. VL enhances first-pass success in experienced hands, especially in ICUs. Larger trials are needed to confirm broader applicability. This study advances prior work by focusing on high-acuity settings and rigorous methodologic standards. This review is registered with PROSPERO (http://www.crd.york.ac.uk/PROSPERO, CRD42023458066).