Video Laryngoscopy in Airway Management

The Macintosh direct laryngoscope, introduced in 1943, remained the undisputed gold standard for tracheal intubation for over 60 years. The first commercially available video laryngoscopes (GlideScope, 2001; C-MAC, Airtraq) emerged in the early 2000s, initially positioned exclusively as rescue devices for anticipated difficult airways. Early observational studies and case series demonstrated that video laryngoscopy consistently provided superior glottic visualisation compared to direct laryngoscopy, particularly in patients with predicted difficult airways. The critical signal was that improved visualisation did not always translate to improved first-pass success — operators needed training in the 'look around the corner' technique unique to hyperangulated blades, and the disconnect between 'seeing' and 'tubing' became an important early lesson.

The evidence base for video laryngoscopy matured through a series of increasingly rigorous studies. A Cochrane review (2016) of 64 studies found that video laryngoscopy reduced failed intubations (particularly in predicted difficult airways) and improved glottic view, though the evidence for routine use in normal airways was less clear. The INTUBE study (2021) — a large international observational study of 2,964 tracheal intubations in critically ill patients — found that video laryngoscopy use was associated with higher first-attempt success compared to direct laryngoscopy (79.6% vs 71.1%). The DEVICE trial (2022) randomised 1,404 critically ill adults to video versus direct laryngoscopy for first intubation attempt and demonstrated significantly higher first-attempt success with video laryngoscopy (85.1% vs 70.8%). These studies collectively shifted the paradigm from video-as-rescue to video-as-default.

The pandemic accelerated video laryngoscopy adoption as a safety measure, since the physical distance between operator and patient during video-assisted intubation reduced aerosol exposure. Beyond the ICU, video laryngoscopy has been evaluated across settings. The MACMAN trial in the prehospital environment and the VivAIS study in emergency departments provided additional context. The development of Macintosh-geometry video laryngoscopes (C-MAC, McGrath MAC) was particularly important — these blades allow both direct and indirect visualisation, addressing the criticism that hyperangulated blades make intubation harder despite better views. Portable, disposable video laryngoscopes have made the technology accessible in resource-limited settings and prehospital environments. Training paradigms have also shifted, with several programmes now teaching video laryngoscopy as the primary technique from the outset.

The 2022 Difficult Airway Society (DAS) guidelines recommend video laryngoscopy as the first-choice technique for all tracheal intubations, not just difficult airways — a paradigm shift from rescue to default. The ASA 2022 updated practice guidelines for difficult airway management recommend that video laryngoscopy be available for all intubations and considered as an initial approach. The Association of Anaesthetists 2023 guidelines state that video laryngoscopy should be immediately available for every anaesthetic where intubation is planned, and many institutions have adopted video-first policies.

Video laryngoscopy has transitioned from a rescue device to the recommended first-line technique for tracheal intubation in most developed-world anaesthesia and critical care settings. The key debate has shifted from 'whether to use' to 'which blade geometry' — hyperangulated blades offer superior views but require a styletted tube technique, while Macintosh-geometry blades allow both direct and indirect visualisation with familiar intubation mechanics. Training programmes are increasingly teaching video laryngoscopy as the primary technique, with direct laryngoscopy as a backup skill. Current frontiers include AI-assisted real-time guidance during intubation, integration of video laryngoscopy with electromagnetic tracking for nasal intubations, and the development of low-cost disposable devices for global health settings. The question is no longer if video laryngoscopy should be used, but how to ensure universal access and competency.