A randomized clinical trial involving 2532 adults in operating rooms has found that video laryngoscopy significantly improves the chances of successfully placing a breathing tube on the first attempt compared with conventional direct laryngoscopy. The findings suggest that video-based airway devices may offer a more reliable approach for routine tracheal intubation and could accelerate a broader shift in operating-room practice.
The study compared three commonly used techniques. One group underwent direct laryngoscopy, in which clinicians align the mouth, pharynx, and larynx to view the vocal cords directly with a traditional laryngoscope. The other patients were intubated using video laryngoscopes, which transmit an image from a camera near the blade tip to a screen. Video laryngoscopy was evaluated with both a Macintosh-style blade, designed to resemble the curved blade used in direct laryngoscopy, and a hyperangulated blade, which has a more pronounced curve intended to improve the view of the larynx in challenging airway geometries.
First-pass success was achieved in 78.2% of patients assigned to direct laryngoscopy. The rate rose to 82.9% among patients intubated with video laryngoscopy using a Macintosh blade, known as VLM, and reached 87.6% with video laryngoscopy using a hyperangulated blade, known as VLH. According to the study, both video laryngoscopy strategies produced significantly higher first-pass success rates than direct laryngoscopy.
The difference is clinically important because every additional attempt at intubation can increase the risk of airway trauma, bleeding, oxygen desaturation, and other complications. Repeated attempts may also prolong the period during which a patient is unable to breathe independently. By placing a camera close to the tip of the blade, video laryngoscopy can provide an indirect view of the vocal cords without requiring clinicians to create the same line of sight needed for direct laryngoscopy.
The hyperangulated blade produced the highest success rate in the trial. Its pronounced curvature can help the operator look around the tongue and other structures that may obstruct the direct view of the larynx. However, the technique also requires specific handling. Once the vocal cords are visualized, advancing the tube through the sharply curved pathway can demand precise coordination, and clinicians often use a shaped stylet to guide the tube. A clear view on the screen therefore does not, by itself, guarantee uncomplicated tube delivery.
The Macintosh-style video blade performed better than direct laryngoscopy while preserving a familiar blade design. This may make it easier for clinicians trained in conventional laryngoscopy to incorporate video technology into everyday care. The screen can also allow assistants and other members of the operating team to see the airway, potentially improving communication during the procedure and making instruction or supervision more effective.
The trial was conducted in the operating-room environment, where patients are generally prepared for anesthesia and airway management is performed under controlled conditions. The results therefore provide strong evidence for routine surgical intubation, but they do not automatically establish that the same performance will occur in emergency departments, intensive care units, ambulances, or prehospital settings. In those environments, patients may have blood or vomit in the airway, limited oxygen reserves, restricted access to the head, or rapidly changing physiology. Device performance can also depend on operator experience, patient anatomy, and the availability of backup equipment.
Despite those considerations, the findings add to growing evidence that video laryngoscopy can improve the reliability of initial airway management. The study’s results support the use of video laryngoscopy as a new standard of care for routine intubation, particularly when equipment, training, and institutional protocols are in place. The choice between a Macintosh-style and hyperangulated blade may still depend on the patient, the clinician’s expertise, and the specific clinical situation.
Benedikt Schmid, MD, PhD, of the Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine at University Hospital Würzburg in Germany, is the study’s corresponding author. Published in JAMA Network Open, the randomized trial offers a large-scale comparison of three major laryngoscopy approaches and places first-pass success at the center of airway quality. Its central message is straightforward: in routine operating-room care, seeing the airway through a video screen was associated with a greater likelihood of successful intubation on the first attempt than relying on direct vision alone.
Subject of Research: First-pass tracheal intubation success using direct laryngoscopy and video laryngoscopy with Macintosh and hyperangulated blades in adult operating-room patients.
Web References: https://doi.org/10.1001/jamanetworkopen.2026.25965
References: Schmid B et al. Randomized clinical trial of direct laryngoscopy, video laryngoscopy with a Macintosh blade, and video laryngoscopy with a hyperangulated blade. JAMA Network Open. DOI: 10.1001/jamanetworkopen.2026.25965.
Keywords: tracheal intubation, airway management, video laryngoscopy, direct laryngoscopy, Macintosh blade, hyperangulated blade, first-pass success, randomized clinical trial, anesthesia, operating room.
