Look Before You Leap: What the JAMA 2024 Video Laryngoscopy Trial Means for Your Airway Practice
The airway that almost wasn't
It is three in the morning, and a young woman is wheeled into my resuscitation bay with a gunshot wound to the face. The airway is bleeding, the anatomy is distorted, and she needs a tube immediately. I do what most of us do in 2026 — I reach for the video laryngoscope, slide in a hyperangulated blade, and look up at the screen. Within about four seconds I can no longer see a single landmark. The lens is painted red. I have a beautiful, high-definition view of nothing. My second attempt is a standard Macintosh blade, direct laryngoscopy, eyes down at the mouth. The tube goes in. Done.
I do not open with that story to flex about a save. I open with it because it sits at the exact tension at the heart of today's paper: when does the new technology beat the old, and when does the old technology save you from the new?
Why this paper matters
Across all settings, roughly 8 per cent of patients require more than one attempt at endotracheal intubation.* That figure sounds small until you remember what a second attempt costs — hypoxemia, hypotension, aspiration, airway trauma, and in the worst case, cardiac arrest. Every additional attempt is a step closer to the cliff. So the practical question for anyone who manages airways is whether a piece of kit or a change in workflow can reliably drop that multi-attempt rate.
Video laryngoscopy arrived in 2001 with exactly that promise. Instead of asking the operator to align the mouth, pharynx, and larynx into a single line of sight, a camera at the tip of the blade does the work and returns the image to a screen at eye level. In theory, that solves the visualization problem. In practice, the evidence has been genuinely mixed. A 2017 ICU trial found that video laryngoscopy did not improve first-pass success and was associated with more severe complications, including cardiac arrest and severe hypoxemia4. A 2022 Cochrane review found only a small benefit, on low-certainty evidence5. Yet large effectiveness trials in trauma and emergency departments have shown a clear video benefit6. Heading into 2024, the question for routine surgical patients was still open: which device should we reach for first?
The trial, in brief
Ruetzler and the Cleveland Clinic group1 studied 8,429 surgical procedures in 7,736 adults at a single US academic center between March 2021 and December 2022. These were adults aged 18 or older undergoing cardiac, thoracic, or vascular surgery — elective or emergent — who required a single-lumen endotracheal tube for general anesthesia. The median age was 66, 35 per cent were women, and 85 per cent of cases were elective. Notably, 81 per cent of patients were ASA physical status 4, meaning life-threatening systemic illness. This is a bread-and-butter major-surgery population: not the chaotic, undifferentiated airway of the ED, but not low-risk either.
The design is the clever part. The investigators treated two sets of eleven operating rooms as clusters and randomized them on a one-week rotating basis to perform either video or direct laryngoscopy for the initial attempt. Every week, half the floor used one technique and the other half used the other, and the next week they flipped. The video device was a GlideScope with a hyperangulated blade; the comparator was a Macintosh of the same size. A stylet was mandated for video and left to preference for direct. Most intubations were performed by residents, fellows, or nurse anesthetists, with attending anesthesiologists doing only about 3 per cent of first attempts — a detail worth holding onto. The primary outcome was the number of intubation attempts per procedure, analyzed as an ordinal variable; the key secondary outcomes were intubation failure (switching devices or needing more than three attempts) and a composite of airway and dental injury.
What it found
The numbers are striking. More than one attempt was required in 1.7 per cent of video-laryngoscopy procedures (77 of 4,413) compared with 7.6 per cent of direct procedures (306 of 4,016). The estimated proportional odds ratio for the number of attempts was 0.20 (95% CI, 0.14 to 0.28; P < .001) — in plain terms, a patient randomized to video had roughly 80 per cent higher odds of needing fewer attempts. That is an enormous effect size for the airway literature, where we almost never see relative differences this large.
The failure outcome is even more dramatic. Intubation failure occurred in 0.27 per cent of video procedures (12 of 4,413) versus 4 per cent of direct procedures (161 of 4,016) — a relative risk of 0.06, a roughly fifteen-fold reduction, and an absolute difference of about 3.7 per cent in favor of video. Meanwhile, the composite of airway and dental injury was about 1 per cent in each group and statistically indistinguishable. That last result is a reassuring null: video laryngoscopy did not introduce the new harms that earlier ICU data had raised as a concern.
Strengths and limitations
This is the part of journal club where you stop being a fan and start being a critic. I love the result, but loving a result is not a reason to ignore the design. On the strengths side, the sample size is enormous for an airway trial, and it was stopped at the second interim analysis because the efficacy signal was so consistent. The cluster-crossover design is pragmatic and reduces selection bias, since clinicians could not cherry-pick easy patients for one device. The result is mechanistically coherent — a hyperangulated blade with a tip camera should give a better view of an anterior airway — and it is consistent with a converging body of evidence across emergency, pre-hospital, and critical-care settings⟦2,3⟧.
The limitations are equally real. This was a single center — an exceptional academic institution with deep training programs and early technology adoption — so a community hospital may not reproduce the same effect size. The population was narrow: well-fasted, well-positioned, well-oxygenated patients on an operating table, often with a senior attending nearby. That is not the airway I intubate at three in the morning with bodily fluids on the floor. The biggest issue for those of us in emergency and pre-hospital medicine is the blade itself: the trial used a hyperangulated video blade, not a standard-geometry one, which biases the comparison toward video for difficult anterior airways and tells us nothing about how a standard-geometry video blade would perform. Operators were also predominantly trainees, whose direct laryngoscopy skills are, on average, less practiced than their video skills — so the trial may be measuring an operator-skill gradient as much as a device-performance gradient. Finally, it was open-label by necessity, which leaves room for co-intervention bias, particularly in the rescue-device outcome.
How should this modify your practice?
Here is how I have actually changed my practice in response to this trial and the broader literature. First, if video laryngoscopy is available, it is my default first-pass tool — the data across the OR, ED, ICU, and pre-hospital settings now point the same way, and the only good reason not to default to video is not having access to it.
Second — and this is where I diverge from the Cleveland Clinic protocol — I almost always reach for a standard-geometry blade rather than a hyperangulated one. A standard-geometry blade gives you optionality: you can look up at the screen and use the video, or, if the camera fails in a dirty airway, you can look down at the mouth and perform direct laryngoscopy with the very same blade. You change your gaze, not your device. A hyperangulated blade removes that fallback, because its geometry is wrong for direct visualization; if the camera is contaminated, you are committed to a device swap. In the gunshot-wound airway I described, that swap cost me an attempt, time, and oxygen reserve.
Third, consider bougie ergonomics. I am a bougie-first operator for most intubations, and I have never found a hyperangulated blade comfortable with a bougie — the angle is awkward, and the rigid stylets these systems use do not conform around airway corners the way a bougie does. Standard-geometry video plus bougie is, for my hands, the optimal setup. Fourth, and most important for trainees: do not let video laryngoscopy erode your direct laryngoscopy skills. I respond to hospital-wide codes in places without a video laryngoscope immediately at hand, and in the seconds before the C-MAC tower arrives I need to intubate with a Macintosh and a head-tilt-chin-lift. That skill atrophies if you never use it. So on lower-risk airways I set up for video but deliberately look down first; if I get a Cormack-Lehane grade 1 or 2, I intubate from there, and if I do not, I look up and convert to the screen. You get the safety net of video without losing the muscle memory of direct.
The bottom line
In adults undergoing cardiac, thoracic, or vascular surgery, hyperangulated video laryngoscopy reduced intubation attempts and rescue-device use compared with direct, with no increase in injury. For routine OR intubations, that is practice-changing. For the messier world of emergency and pre-hospital airways, it is informative but not the final word — default to video, but choose your blade geometry deliberately, build redundancy into your workflow, and keep your direct skills alive. Be prepared, not scared.
About the author
Dr Adrian Cois is an Emergency Medicine physician and Assistant Professor of Emergency Medicine, and the creator of Overheard in the Emergency Room — evidence-based medicine for everyday people. He writes and records at DrCois.com.
Disclosure: Dr Cois has no financial relationship with any device manufacturer named in this article, including Verathon (GlideScope), Karl Storz (C-MAC), or any bougie or stylet manufacturer. He maintains a standing disclosure of no financial relationship with any product or company mentioned across Overheard episodes. This article is for educational purposes only.
Related reading
• Overheard Journal Club Ep 1 — SALT-ED: balanced crystalloids in the ED* (DrCois.com)
• Overheard Journal Club Ep 2 — Fluoride: reading a public-health paper critically* (DrCois.com)
• Overheard in the ER — the bougie-first episode referenced on air* (DrCois.com)
References (AMA)
1. Ruetzler K, Bustamante S, Schmidt MT, et al. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024;331(15):1279-1286. doi:10.1001/jama.2024.0762
2. Arulkumaran N, Lowe J, Ions R, Mendoza M, Bennett V, Dunser MW. Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Br J Anaesth. 2018;120(4):712-724. doi:10.1016/j.bja.2017.12.041
3. Pourmand A, Terrebonne E, Gerber S, Shipley J, Tran QK. Efficacy of Video Laryngoscopy versus Direct Laryngoscopy in the Prehospital Setting: A Systematic Review and Meta-Analysis. Prehosp Disaster Med. 2022:1-11. doi:10.1017/S1049023X22002254
4. Lascarrou JB, Boisrame-Helms J, Bailly A, et al. Video Laryngoscopy vs Direct Laryngoscopy on Successful First-Pass Orotracheal Intubation Among ICU Patients: A Randomized Clinical Trial. JAMA. 2017;317(5):483-493. doi:10.1001/jama.2016.20603
5. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022;4(4):CD011136. doi:10.1002/14651858.CD011136.pub3
6. Prekker ME, Driver BE, Trent SA, et al; DEVICE Investigators. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023;389(5):418-429. doi:10.1056/NEJMoa2301601
