Written by Aaron Lacy
Spoon Feed
In this systematic review and meta-analysis of video laryngoscopy (VL) versus direct laryngoscopy (DL) for intubation in cardiac arrest, low-certainty evidence favored VL for improved first-attempt success (FAS) and decreased esophageal intubation. There was no impact on patient-centered outcomes, such as return of spontaneous circulation (ROSC) or survival.
DL = voluntary hardship
While evidence is stacking up for VL over DL (e.g., critically ill patients, prehospital environment, operating room), it’s still unclear which is better for patients in cardiac arrest.
This systematic review and meta-analysis found 3 randomized controlled trials (RCTs) and 13 observational studies covering VL vs. DL in cardiac arrest. Outcomes included FAS, overall success, ROSC, esophageal intubation, survival, and survival with good neurological outcome.
331 patients were included from the 3 RCTs, which found low-certainty evidence of no difference between VL and DL for FAS (RR 0.88; 95%CI 0.63–1.22) or overall success (RR 1.00; 95%CI 0.90–1.12). 2 RCTs focused on out-of-hospital cardiac arrest (OHCA) and one focused on the emergency department (ED).
29,595 patients were included from the 13 observational studies, which generally favored VL for first-attempt and overall success. There were no consistent differences in rates of ROSC, survival, or neurologically intact survival between VL and DL groups. Notably, 9 of the 13 studies were looking at patients with OHCA.
Overall, they also found lower rates of esophageal intubation with VL over DL (4.3% vs. 0% in RCTs, and 5.6% vs. 1.4% in observational studies).
How will this change my practice?
It doesn’t. I am on the VL train. In 2026, you should be asking yourself why you’re not using VL. There is minimal RCT data on cardiac arrest, and the three RCTs included are small and ~10 years old. While considered observational, subanalyses of high-quality RCTs comparing VL vs. DL in cardiac arrest (i.e. DEVICE) favor VL. Cardiac arrest airways are already difficult; using DL just feels like adding trouble to me.
Editor’s note: All observational studies had critical risk of bias, so they did not calculate the overall effect on the Forest plot. Had they done so for FAS: RR 1.20 (95%CI 1.10 to 1.31); combining RCTs and cohort studies for FAS: RR 1.15 (95%CI 1.04 to 1.27). I did my own meta-analysis in minutes, not months. More to come about this! ~Clay Smith
Source
ILCOR Advanced Life Support Task Force. Tracheal intubation using video laryngoscopy as compared to direct laryngoscopy during cardiopulmonary resuscitation: a systematic review and meta-analysis. Resuscitation. 2026 Feb;219:110981. doi: 10.1016/j.resuscitation.2026.110981. Epub 2026 Jan 20. PMID: 41570881.
Why not VL? Almost every study shows it to be superior.
But almost every study was done in an academic environment–with less skilled intubators. What they prove is that VL is better for a novice. While that may also be true for a more experienced operator, the difference is likely much smaller. It takes more practice to both develop the initial DL skill set and to maintain it. Yes, there are certain circumstances where I agree VL as a primary modality is preferred. But I’ve also had circumstances clinically where VL was not immediately available. It’s always better to have a GOOD backup. With solid DL skills, VL is a fantastic backup. If VL is one’s routine, primary approach, DL is likely a poor backup.
(1/2) Hi Dr Puller! Thanks for the comments. VL is swiftly becoming more ubiquitous, so situations in US based EDs (even rural) where not having VL is becoming less likely (PMID 39665719). Additionally, would argue this is an operational decision from hospital/departmental leadership, not a true unavailability of the technology. This of course, does not hold up everywhere around the world. You make a good point that the studies were done at academic centers and mostly by trainees (like DEVICE, BOUGIE), but they did track operators prior experience and VL still performed better in the hands of almost all experienced operators. The only category of operator that favored DL over VL was if they had done >100 intubations in which less than ~25% of those intubations were with VL. All other categories favored VL if they had enough hands-on time with VL (PMID 37326325, Figure S7). This type of procedural experience is unlikely to describe ED docs with <10 years of experience or coming out of residency now.
(2/3) Lastly, using VL primarily does not mean that you shouldn’t understand and be familiar with DL as a backup. The philosophical educational question here is if proficiency with DL in trainees is set at a higher number (see supplemental figures of Device trial), and average intubation numbers in residency for ETIs are in the 80/90s across the US, should we train them more on the backup or the best primary method? There is a chance they may not reach proficiency in training. It is also shown that the microskills gained from the psychomotor feedback from learning ETI with real time video guidance and coaching has been shown to improve performance, including DL performance later, and that learning VL first might be the key to building blocks of learning DL. This was discussed in a Point|Counterpoint article series in Annals in August of 2024, which we covered in JF on August 12 and 13. Additionally, a systematic review and meta analysis on that exact question was done in late 2025, finding that VL is at least as effective, if not better, for teaching DL than doing DL itself (PMID 40634187).
(3/3) Lastly, in terms of backup/rescue the frequency of DL saving failed intubation with trained VL is extremely low, while >90% of all DL failures are saved by VL in numerous published series (most notably PMID 27483124). This all precludes my takeaway from this article – in this specific type of intubation, cardiac arrest, it probably isn’t the time to primarily reach for DL. The argument of DL vs VL in more standard airways and in education is more nuanced, as above.
best – and always down to chat airways!
aaron