SCCMPod-545 CCM: Improving Intubation in Critical Illness

Aug 14, 2025

Ben Forestell, an emergency and critical care medicine specialist, and Garrett McDougall, an emergency medicine trainee, dive into their research comparing direct and video laryngoscopy for intubation in critically ill patients. They reveal surprising findings, including equal benefits from standard and hyperangulated video devices. The discussion highlights video laryngoscopy's potential to improve first-pass success rates and reduce severe complications, emphasizing the need for ongoing research in critical care and difficult airway management.

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ANECDOTE

COVID Drove Routine VL Use

During COVID, McMaster shifted almost exclusively to hyperangulated VL to reduce aerosols and improve first-pass success.
That local practice change motivated their research question about VL's benefits.

INSIGHT

Heterogeneity Limits Precision

Heterogeneity in patients, operator experience, device types, and co-interventions limits certainty and information size.
Trial sequential analysis suggests direction of benefit is unlikely to change despite incomplete information size.

INSIGHT

VL Raises First-Pass Success

Video laryngoscopy (VL) probably increases first-pass success by about 10% in critically ill patients.
This benefit appears across operator experience but is strongest for novice intubators.

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In this episode of the Society of Critical Care Medicine (SCCM) Podcast, host Kyle B. Enfield, MD, FCCM, speaks with Garrett McDougall, MS, MSc, and Ben Forestell, MD, of McMaster University about their recent study, “Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials,” published in the November 2024 issue of Critical Care Medicine. The study included 20 randomized controlled trials encompassing 4569 patients to investigate whether video laryngoscopy (VL) offers advantages over direct laryngoscopy (DL) for intubation in critically ill patients.

A key finding of the study was that VL probably improves first-pass success rates and reduces the risk of esophageal intubation and dental injury. These benefits extend across the spectrum of operator experience, especially among novice operators but also among seasoned operators.

Drs. McDougall and Forestell discuss findings that surprised them, such as seeing equal benefit for standard VL and hyperangulated VL devices. Additionally, no clear benefits were found for patients who were intubated emergently with VL as compared to those who underwent elective intubation.

The discussion covers what could be next for resuscitation and airway research in critically ill patients. There may be more to learn about scenarios involving difficult airways, soiled airways, and emergent versus elective intubation. More research on device characteristics could also provide important insights.

To wrap up, the guests underscore the importance of maintaining both VL and DL proficiency since DL can be a more appropriate choice for some patients.

Resources referenced in this episode:

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials (McDougall GG, et al. Crit Care Med. 2024;52:1674-1685).