Is a Miller laryngoscope better than a video laryngoscope for newborn intubation?

Video Laryngoscopy is Superior to Miller Laryngoscope for Neonatal Intubation

Video laryngoscopy should be used preferentially over the Miller (traditional) laryngoscope for neonatal intubation when resources and training allow, particularly when less-experienced clinicians are performing the procedure. 1, 2

Evidence-Based Recommendation

The 2025 ILCOR and AHA/AAP guidelines both recommend video laryngoscopy based on high-quality evidence from 6 RCTs involving 862 intubations 1, 2. The data demonstrates:

Primary Outcomes Favoring Video Laryngoscopy:

• First-attempt success rate: 57% higher with video laryngoscopy (RR 1.57,95% CI 1.33-1.85) - this is HIGH certainty evidence 1
• Overall intubation success: 43% higher with video laryngoscopy (RR 1.43,95% CI 1.15-1.77) - moderate certainty evidence 1
• Reduced adverse events: Lower odds of desaturation (OR 0.62) and airway trauma (OR 0.24) 3

Practical Translation:

For every 1000 intubations, video laryngoscopy results in 225 more successful first attempts compared to Miller laryngoscopy (130-335 more per 1000) 1. This translates directly to reduced patient morbidity from multiple attempts.

Safety Profile

Critically, no increased harm was demonstrated with video laryngoscopy - adverse events including airway trauma, bradycardia, desaturation, esophageal intubation, and pneumothorax were not increased across 5 RCTs 2. In fact, trauma and desaturation were significantly reduced 3.

Clinical Context and Nuances

The evidence base includes both delivery room and NICU settings, though approximately 80% of intubations studied occurred in the NICU 1. The recommendation applies across both settings.

Important Caveats:

• Always have a Miller laryngoscope available as backup - this is a good practice statement from ILCOR 1
• Traditional laryngoscopy remains reasonable when video laryngoscopy is unavailable due to cost or training constraints 1, 2
• The benefit is particularly pronounced for less-experienced operators 1

Time to Intubation

While some individual studies show marginal differences, meta-analyses demonstrate no clinically significant difference in total intubation time between video and Miller laryngoscopy 3, 4. Video laryngoscopy provides faster glottic visualization but may require slightly longer tube passage time, resulting in equivalent overall times 4, 5.

Device-Specific Considerations

Among video laryngoscopes, the C-MAC with Miller blade demonstrated the shortest intubation times (median 27 seconds) and best glottic visualization in head-to-head comparisons 6. However, multiple video laryngoscope platforms (C-MAC, GlideScope, Besdata, NeoView) have all shown superiority over traditional Miller laryngoscopy 6, 4, 7, 8.

Bottom Line Algorithm

For neonatal intubation:

1. First choice: Video laryngoscope (if available and staff trained)
2. Backup/Alternative: Miller laryngoscope (always immediately available)
3. Contraindication to video laryngoscopy: None identified

The recommendation is conditional due to resource and training requirements, but the evidence direction is clear and consistent across multiple high-quality studies and international guidelines.