Direct- versus video laryngoscopy during suction assisted laryngoscopy and airway decontamination (SALAD): A randomized controlled simulation study

Pulmonary aspiration during airway management is associated with increased morbidity and mortality. First-pass success during tracheal intubation is a key determinant of patient safety and has been shown to improve with videolaryngoscopy (VL). However, comparative evidence regarding hyperangulated VL and direct laryngoscopy (DL) during massive airway contamination remains limited, particularly within a standardized Suction-Assisted Laryngoscopy and Airway Decontamination (SALAD) workflow. This study aimed to compare DL and hyperangulated VL in a standardized SALAD simulation model. In this 1:1 randomized controlled simulation study, physicians performed tracheal intubation using a standardized regurgitation model. Participants were randomized to hyperangulated VL or DL. The primary endpoint was first-pass success (FPS). Secondary endpoints included time to successful tracheal intubation and time to first successful ventilation. Two hundred physicians from various specialties were enrolled and randomized. FPS was significantly higher in the VL group than in the DL group (94.0% vs. 58.0%; OR 11.34, 95% CI 4.54-28.35; p < 0.001). Time to successful tracheal intubation was significantly shorter in the VL group (median [IQR]: 34 s [29-40] vs. 41 s [35-48]; p < 0.001). Likewise, time to first ventilation was significantly reduced (median [IQR]: 40 s [34-44] vs. 45 s [40-53]; p < 0.001). In multivariable logistic regression analysis, VL remained independently associated with FPS (adjusted OR 13.42, 95% CI 5.18-34.78; p < 0.001), whereas age, sex, professional experience, specialty, and additional qualifications were not significantly associated with the primary outcome. In this simulation model of massive airway contamination, hyperangulated videolaryngoscopy significantly improved first-pass success and reduced both intubation and ventilation times compared with direct laryngoscopy during SALAD-assisted airway management. Whether these procedural advantages translate into improved patient-centered outcomes requires confirmation in future clinical studies. Trial Registration The registration of the clinical trial was initiated prospectively on July 15, 2024, in the German Clinical Trials Register (DRKS00034683).