Advancing emergency airway management: Video laryngoscope vs intubating laryngeal mask airway in critical care

Abstract

This editorial comments on the randomized controlled trial by Aggarwal et al, which demonstrates video laryngoscope (VL) superiority over intubating laryngeal mask airway (ILMA) for emergency intubation in critically ill patients-first-pass success (87.5% vs 53.1%), intubation times (44.0 ± 19.7 seconds vs 82.5 ± 14.5 seconds), and reduced complications including oral trauma (0% vs 26.9%) and sore throat (3.1% vs 26.9%). VL’s camera-enhanced visualization ensures precise navigation in high-stakes scenarios where patients have limited physiological reserve, positioning it as the frontline device per updated Difficult Airway Society guidelines. ILMA retains value as rescue ventilation during failed VL attempts despite its longer procedure times and tissue trauma risks, warranting availability in all emergency airway algorithms. These rigorous findings guide intensivists toward protocol revisions prioritizing VL training, resource allocation, and simulation drills-particularly in resource-limited intensive care units. Future multicenter trials should validate performance across difficult airways and evaluate cost-effectiveness to optimize implementation globally.

Key Words: Airway management; Critical care; Emergency intubation; Intubating laryngeal mask airway; Video laryngoscope; First-pass success; Resource-limited settings

Core Tip: This editorial highlights Aggarwal et al’s trial showing video laryngoscopy (VL) outperforming intubating laryngeal mask airway (ILMA) in critically ill patients, with higher first-attempt success (87.5% vs 53.1%), faster intubation (44.0 ± 19.7 seconds vs 82.5 ± 14.5 seconds), and fewer complications. Superior glottic visualization positions VL as first-line for emergency airways, with ILMA as rescue. Findings advocate protocol revisions, VL training, and resource prioritization for better outcomes.

INTRODUCTION

Airway management remains a cornerstone of critical care, especially in emergency settings where patients often have deteriorated physiological reserve and anatomical challenges[1].

Emergency airway management is a vital lifesaving intervention but carries significant risks, including hypoxia, hypotension, cardiac arrest, and death, which can occur in up to 24%-28% of critically ill patients undergoing intubation[2]. In complex scenarios like cannot intubate, cannot oxygenate emergencies-exemplified by patients with tracheoesophageal fistula post-laryngectomy-advanced devices like video laryngoscope (VL) enhance visualization, while intubating laryngeal mask airway (ILMA) supports ventilation during attempts[3,4].

This editorial comments on the randomized controlled trial by Aggarwal et al[5], comparing VL and ILMA for emergency intubation in critically ill patients. Aggarwal et al[5] address a pivotal question in airway management-which device better ensures successful, timely intubation under high-stakes conditions-through rigorous randomization and evaluation.

COMPARISON OF ILMA AND VL

Intubation success and time

Aggarwal et al[5] demonstrated VL superiority over ILMA in 64 critically ill patients, with first-attempt success rates of 87.5% (VL) vs 53.1% (ILMA) and intubation times of 44.0 ± 19.7 seconds (VL) vs 82.5 ± 14.5 seconds (ILMA) (Table 1, Figure 1). These findings align with prior studies, including Jakhar et al[6] (96.97% VL vs 81.25% ILMA) and Tienpratarn et al[7] (96.88% VL vs 81.25% ILMA), confirming VL's consistent efficiency across contexts. Additional evidence shows VL first-attempt success ranging from 80% to 83.3% in intensive care unit (ICU) and emergency settings, supporting its preferential use[8].

Figure 1 Bar chart displaying total intubation time (mean ± SD), oxygen saturation trends over procedure intervals (mean ± SD), and complication rates (%) between video laryngoscope (n = 32) and intubating laryngeal mask airway (n = 26/32) groups. Data demonstrate video laryngoscope (VL)’s superior efficiency and safety profile. A: Shows intubation time as a bar chart with VL (44.0 ± 19.7 seconds) significantly shorter than intubating laryngeal mask airway (ILMA) (82.5 ± 14.5 seconds); B: Displays dual line graphs of SpO₂ trends over six timepoints, both stable above 95% post-insertion; C: Uses grouped bars for complications, highlighting ILMA’s higher rates across all categories. ILMA: Intubating laryngeal mask airway; VL: Video laryngoscope.

Table 1 Intubation success rates and attempts - video laryngoscope vs intubating laryngeal mask airway groups, n (%).

Outcome	Video laryngoscope group (n = 32)	Intubating laryngeal mask airway group (n = 32)
First-attempt success	28 (87.5)	17 (53.1)
Attempts distribution
1 attempt	28 (87.5)	17 (53.1)
2 attempts	4 (12.5)	7 (21.9)
3 attempts	0 (0)	2 (6.2)
Failed intubation	0 (0)	6 (18.8)

Safety profile

VL maintained stable oxygen saturation (no desaturation) and hemodynamic parameters comparable to ILMA, with fewer complications: No peri-intubation mouth damage (0% VL vs 26.9% ILMA), lower sore throat incidence (3.1% VL vs 26.9% ILMA), and minimal esophageal intubation (3.1% VL vs 7.7% ILMA) (Figure 1). ILMA’s blind insertion increased tissue trauma risks, underscoring VL’s visualization advantage in emergency settings.

Literature engagement

The differential performance between VL and ILMA largely stems from intrinsic design differences. VL’s camera-assisted visualization enables precise airway navigation, reducing intubation failures and shortening procedure duration[9], an advantage particularly critical for patients with limited cardiorespiratory reserves where every second of hypoxia impacts outcomes. This study corroborates prior meta-analyses advocating VL’s benefits and extends knowledge by directly comparing it with ILMA, a widely used alternative device[10].

While the study excluded difficult airway cases, limiting broad generalizability, it provides valuable evidence supporting routine use of VL in emergency protocols[11]. The single-center, relatively small sample size suggests cautious interpretation, but consistent alignment with existing literature strengthens the rationale for VL’s preferential adoption. Additionally, research on endotracheal reintubation in the prone position demonstrates that VL (Glidescope^®) outperforms ILMA combined with fiberoptic assistance, further supporting VL’s superior intubation success and efficiency[12]. Collectively, these findings emphasize the need for ongoing training and resource allocation towards VL integration in clinical practice, to improve airway management outcomes in critically ill patients. Future research should explore VL’s role in difficult airway scenarios and diverse populations to fully optimize emergency airway management strategies.

Critical appraisal

Aggarwal et al’s sample (n = 64) yielded statistically significant differences (e.g., first-attempt success P < 0.05) despite no formal power calculation statement[5], suggesting adequate detection for primary outcomes. The single-center design limits generalizability; multicenter trials across diverse ICU populations would strengthen external validity. Exclusion of predicted difficult airways likely underestimates VL’s real-world advantage, as unanticipated challenges prevail in routine ICU intubations where VL’s visualization edge proves most valuable. Uniform operator expertise minimized learning curve bias but restricts applicability to novice practitioners, emphasizing the need for simulation training in protocol implementation.

Clinical implications and practice recommendations

First-line device selection: VL carry higher upfront costs than ILMA, but offer greater versatility through reusable handles with multiple blade sizes compatible across patients, potentially offsetting expenses in high-volume ICUs. ILMAs provide autoclaving/reuse advantages but require size-specific variants for different endotracheal tubes, plus demonstrate higher failure rates (18.8% after three attempts) and complications (26.9% oral trauma), impacting lifecycle economics.

VL achieves superior first-attempt success (87.5% vs 53.1%), faster intubation times (44.0 ± 19.7 seconds vs 82.5 ± 14.5 seconds), and lower complication rates than ILMA, establishing VL as the preferred first-line device for emergency intubation in critical care. This performance edge supports VL’s reliability in high-stakes scenarios, where rapid airway securement is critical for survival in patients with limited physiological reserve. The shift aligns with Difficult Airway Society 2025 guidelines prioritizing VL in emergencies and ICU airway consensus recommendations for VL first-line, with ILMA reserved as rescue[13,14].

Rescue strategy planning: ILMA retains value as an immediate backup when VL fails, offering ventilation during attempts despite its 18.8% failure rate after three tries (Table 1). Protocols should mandate ILMA availability alongside VL, with predefined escalation to surgical airways for dual-device failures, mirroring guidelines for difficult airway algorithms in intensive care.

Training considerations: Significant performance disparities necessitate prioritizing VL proficiency in critical care curricula, including simulation-based training for emergency providers. Concurrently, ILMA skills must be maintained for rescue roles, with regular multidisciplinary drills to ensure competency across devices and reduce learning curves in novice operators.

Protocol development: Institutions should revise airway management protocols to prioritize VL in time-sensitive emergencies, incorporating preoxygenation, apneic oxygenation, and attempt limits as demonstrated in the study. These updates, supported by consistent literature, can standardize care and minimize hypoxia risks during intubation.

Resource allocation: One versatile VL with multiple blades suffices across cases, unlike ILMA requiring size-specific variants for different endotracheal tubes-potentially offsetting VL’s upfront cost. However, VL demands careful handling and disposable blades/covers, while reusable ILMA supports autoclaving for repeated use, influencing long-term economics in resource-limited settings.

Future research suggestions

Future research should focus on large-scale, multicenter randomized controlled trials in heterogeneous patient populations, including those with predicted difficult airways, to validate these findings across diverse clinical settings[15]. Cost-effectiveness analyses are crucial for guiding airway device procurement and implementation, especially in resource-limited environments like Ethiopia where budget constraints influence equipment choices. Key priorities include trials evaluating VL in difficult airways, economic evaluations in low-resource contexts, learning curves for novice operators to refine training protocols, and long-term outcomes such as ICU length of stay, ventilator-associated complications, and mortality.

CONCLUSION

Aggarwal et al[5] establish VL as the superior first-line device for emergency intubation in critically ill patients, demonstrating higher first-attempt success, faster times, and fewer complications than ILMA. ILMA retains essential utility as rescue/bridge ventilation during failed VL attempts, warranting availability in all emergency airway algorithms. These findings necessitate updated ICU/emergency department protocols prioritizing VL training, simulation drills, and resource allocation to optimize patient outcomes.