Videolaryngoscopy Versus Direct Laryngoscopy in Predicted Difficult Airways: A Comparative Study

Background: Difficult airway management remains a critical challenge in anaesthesia practice, with failed intubation being a leading cause of anaesthesia-related morbidity and mortality. Videolaryngoscopy has emerged as a promising alternative to conventional direct laryngoscopy, offering enhanced glottic visualization through video technology. However, its superiority in predicted difficult airway scenarios requires robust evidence from well-designed comparative studies. This study aimed to compare the efficacy and safety of videolaryngoscopy versus direct laryngoscopy in patients with predicted difficult airways undergoing elective surgical procedures.

Methods: This prospective comparative study was conducted at Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, from February 2024 to June 2025. A total of 500 adult patients with predicted difficult airways, as identified by preoperative airway assessment scores, were allocated to either the videolaryngoscopy group (n=250) or the direct laryngoscopy group (n=250) based on alternate allocation method. Primary outcomes included first-attempt intubation success rate, time to intubation, and Cormack-Lehane grading. Secondary outcomes encompassed hemodynamic parameters, intubation-related complications, and overall intubation difficulty score.

Results: The videolaryngoscopy group demonstrated significantly higher first-attempt intubation success rates compared to direct laryngoscopy (88.4% vs 72.8%, p<0.001). Mean intubation time was comparable between groups (42.3±12.6 seconds vs 45.8±15.2 seconds, p=0.065). Videolaryngoscopy provided superior glottic visualization with significantly better Cormack-Lehane grades (Grade I-II: 84.0% vs 61.6%, p<0.001). The incidence of intubation-related complications, including mucosal trauma and dental injury, was significantly lower in the videolaryngoscopy group (6.4% vs 14.8%, p=0.003). Hemodynamic stability was better maintained with videolaryngoscopy.

Conclusion: Videolaryngoscopy significantly improves first-attempt intubation success rates and reduces complications in patients with predicted difficult airways compared to conventional direct laryngoscopy. The enhanced glottic visualization provided by videolaryngoscopy translates into improved patient safety outcomes. These findings support the integration of videolaryngoscopy as the preferred intubation technique for managing predicted difficult airways in routine anaesthesia practice.