In an adult requiring rapid‑sequence induction, is using a videolaryngoscope the best method to manage an emergency airway?

Videolaryngoscopy for Emergency Airway Management in Rapid Sequence Intubation

Yes, videolaryngoscopy is superior to direct laryngoscopy for managing emergency airways during rapid sequence intubation in adults, with significantly higher first-pass success rates and fewer complications.

Primary Recommendation

The most recent and highest quality evidence demonstrates that videolaryngoscopy achieves markedly better outcomes than direct laryngoscopy for RSI. A 2024 multicentre RCT comparing the McGrath videolaryngoscope with direct laryngoscopy during RSI showed 94% first-pass success with videolaryngoscopy versus 71.6% with direct laryngoscopy (p < 0.001) 1. This represents a clinically meaningful 22.4% absolute improvement in first-pass success—a critical outcome since multiple intubation attempts increase aspiration risk, the very complication RSI aims to prevent.

Supporting Evidence Framework

Guideline Context

While the 2023 Society of Critical Care Medicine RSI guidelines 2 and 2022 ASA Difficult Airway guidelines 3 acknowledge videolaryngoscopy as an available tool, they provide equivocal recommendations due to mixed evidence quality at the time of publication. However, the most recent high-quality RCT evidence supersedes these earlier guideline positions when prioritizing morbidity and mortality outcomes.

Key Performance Advantages

First-Pass Success Rates:

• The 2024 McGrath RCT demonstrated superiority across both trainees and consultants 1
• A 2020 NEAR registry study of 6,938 ED intubations showed 90.9% success with videolaryngoscopy versus 81.1% with augmented direct laryngoscopy (using bougie, external laryngeal manipulation, and ramping combined), adjusted OR 2.8 (95% CI 2.4-3.3) 4
• This advantage persisted even when direct laryngoscopy was optimized with multiple adjuncts

Improved Glottic Visualization:

• Cormack-Lehane grade ≥3 views occurred in only 1% with videolaryngoscopy versus 19% with direct laryngoscopy 1
• Better visualization translates directly to reduced intubation difficulty

Safety Profile:

• Adverse events occurred in 2.6% with videolaryngoscopy versus 12.2% with direct laryngoscopy 1
• Esophageal intubations were significantly reduced: 0.4% versus 1.3% (adjusted OR 0.2) 4

Practical Implementation

Optimal Technique: Combine videolaryngoscopy with a bougie (Frova introducer) as part of a standardized protocol. A 2018 pre-hospital study using C-MAC videolaryngoscopy with bougie achieved 98.2% first-pass success in RSI 5. This combination addresses both visualization and tube delivery challenges.

Device Selection:

• Both hyperangulated (e.g., McGrath, Airtraq) and standard-geometry videolaryngoscopes (e.g., C-MAC with Macintosh blade) demonstrate superiority over direct laryngoscopy 4
• Channeled videolaryngoscopes (Airtraq) may offer advantages in trauma scenarios with cervical immobilization, achieving faster intubation times (21.8s vs 42.2s with Macintosh) 6

Important Caveats

Experience Level Matters: One 2016 ED study by highly experienced consultants showed equivalent first-pass success (98.6% videolaryngoscopy vs 100% direct laryngoscopy) 7. However, this represents an outlier with ceiling effects—most emergency settings involve varied operator experience levels where videolaryngoscopy's advantages become critical.

Not a Panacea: Videolaryngoscopy improves visualization but doesn't eliminate all difficult airways. Operators must maintain proficiency with multiple techniques and have rescue strategies available.

Clinical Algorithm

1. Default to videolaryngoscopy for all RSI procedures in emergency settings
2. Combine with bougie as standard practice (not rescue)
3. Ensure immediate availability of alternative devices (flexible bronchoscope, supraglottic airways, surgical airway equipment)
4. Limit attempts: If first-pass videolaryngoscopy fails, immediately escalate to alternative technique rather than repeated attempts
5. Maintain direct laryngoscopy skills as backup, particularly for scenarios where videolaryngoscope malfunction or blood/secretions obscure the camera

The evidence strongly supports videolaryngoscopy as the primary technique for emergency RSI, with direct laryngoscopy relegated to backup status or specific scenarios where videolaryngoscopy is unavailable or contraindicated.