Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation

Jan Hansel; Andrew M Rogers; Sharon R Lewis; Tim M Cook; Andrew F Smith

doi:10.1002/14651858.CD011136.pub3

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Figure 1

Flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Blank spaces indicate we did not complete a risk of bias assessment because we were not able to extract any relevant data for our chosen outcomes.

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Figure 4

Funnel plot of comparison: Macintosh‐style videolaryngoscopy versus direct laryngoscopy, outcome 1.1, failed intubation

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Figure 5

Forest plot of comparison: hyperangulated videolaryngoscopy, subgroup analysis of failed intubation in participants with predicted, known or simulated features of airway difficulty

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Figure 6

Funnel plot of comparison: channelled videolaryngoscopy versus direct laryngoscopy, outcome 3.3, successful first attempt

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Analysis 1.1

Comparison 1: Macintosh‐style VL versus DL, Outcome 1: Failed intubation

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Analysis 1.2

Comparison 1: Macintosh‐style VL versus DL, Outcome 2: Hypoxaemia

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Analysis 1.3

Comparison 1: Macintosh‐style VL versus DL, Outcome 3: Successful first attempt

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Analysis 1.4

Comparison 1: Macintosh‐style VL versus DL, Outcome 4: Oesophageal intubation

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Analysis 1.5

Comparison 1: Macintosh‐style VL versus DL, Outcome 5: Dental trauma

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Analysis 1.6

Comparison 1: Macintosh‐style VL versus DL, Outcome 6: Cormack‐Lehane (CL) grade

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Analysis 1.7

Comparison 1: Macintosh‐style VL versus DL, Outcome 7: Time for tracheal intubation

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Analysis 1.8

Comparison 1: Macintosh‐style VL versus DL, Outcome 8: Patient‐reported sore throat

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Analysis 1.9

Comparison 1: Macintosh‐style VL versus DL, Outcome 9: Number of attempts

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Analysis 1.10

Comparison 1: Macintosh‐style VL versus DL, Outcome 10: Intubation Difficulty Scale (IDS)

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Analysis 1.11

Comparison 1: Macintosh‐style VL versus DL, Outcome 11: POGO Score

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Analysis 1.12

Comparison 1: Macintosh‐style VL versus DL, Outcome 12: Mortality

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Analysis 1.13

Comparison 1: Macintosh‐style VL versus DL, Outcome 13: Subgroup analysis of failed intubation: airway difficulty

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Analysis 2.1

Comparison 2: Hyperangulated VL versus DL, Outcome 1: Failed intubation

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Analysis 2.2

Comparison 2: Hyperangulated VL versus DL, Outcome 2: Hypoxaemia

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Analysis 2.3

Comparison 2: Hyperangulated VL versus DL, Outcome 3: Successful first attempt

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Analysis 2.4

Comparison 2: Hyperangulated VL versus DL, Outcome 4: Oesophageal intubation

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Analysis 2.5

Comparison 2: Hyperangulated VL versus DL, Outcome 5: Dental trauma

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Analysis 2.6

Comparison 2: Hyperangulated VL versus DL, Outcome 6: Cormack‐Lehane (CL) grade

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Analysis 2.7

Comparison 2: Hyperangulated VL versus DL, Outcome 7: Time for tracheal intubation

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Analysis 2.8

Comparison 2: Hyperangulated VL versus DL, Outcome 8: Patient‐reported sore throat

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Analysis 2.9

Comparison 2: Hyperangulated VL versus DL, Outcome 9: Number of attempts

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Analysis 2.10

Comparison 2: Hyperangulated VL versus DL, Outcome 10: Intubation Difficulty Scale (IDS)

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Analysis 2.11

Comparison 2: Hyperangulated VL versus DL, Outcome 11: POGO Score

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Analysis 2.12

Comparison 2: Hyperangulated VL versus DL, Outcome 12: Mortality

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Analysis 2.13

Comparison 2: Hyperangulated VL versus DL, Outcome 13: Subgroup analysis of failed intubation: airway difficulty

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Analysis 3.1

Comparison 3: Channelled VL versus DL, Outcome 1: Failed intubation

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Analysis 3.2

Comparison 3: Channelled VL versus DL, Outcome 2: Hypoxaemia

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Analysis 3.3

Comparison 3: Channelled VL versus DL, Outcome 3: Successful first attempt

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Analysis 3.4

Comparison 3: Channelled VL versus DL, Outcome 4: Oesophageal intubation

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Analysis 3.5

Comparison 3: Channelled VL versus DL, Outcome 5: Dental trauma

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Analysis 3.6

Comparison 3: Channelled VL versus DL, Outcome 6: Cormack‐Lehane (CL) grade

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Analysis 3.7

Comparison 3: Channelled VL versus DL, Outcome 7: Time for tracheal intubation

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Analysis 3.8

Comparison 3: Channelled VL versus DL, Outcome 8: Patient‐reported sore throat

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Analysis 3.9

Comparison 3: Channelled VL versus DL, Outcome 9: Number of attempts

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Analysis 3.10

Comparison 3: Channelled VL versus DL, Outcome 10: Intubation Difficulty Scale (IDS)

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Analysis 3.11

Comparison 3: Channelled VL versus DL, Outcome 11: POGO Score

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Analysis 3.12

Comparison 3: Channelled VL versus DL, Outcome 12: Subgroup analysis of failed intubation: airway difficulty

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Analysis 4.1

Comparison 4: VL versus DL (all devices combined), Outcome 1: Failed intubation

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Analysis 4.2

Comparison 4: VL versus DL (all devices combined), Outcome 2: Hypoxia

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Analysis 4.3

Comparison 4: VL versus DL (all devices combined), Outcome 3: Successful first attempt

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Analysis 4.4

Comparison 4: VL versus DL (all devices combined), Outcome 4: Oesophageal intubation

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Analysis 4.5

Comparison 4: VL versus DL (all devices combined), Outcome 5: Subgroup analysis of failed intubation: theatre versus non‐theatre

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Analysis 4.6

Comparison 4: VL versus DL (all devices combined), Outcome 6: Subgroup analysis of failed intubation: obesity

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Analysis 4.7

Comparison 4: VL versus DL (all devices combined), Outcome 7: Subgroup analysis of failed intubation: airway difficulty

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Analysis 4.8

Comparison 4: VL versus DL (all devices combined), Outcome 8: Subgroup analysis of failed intubation: intubator experience

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Summary of findings 1. Macintosh‐style videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Macintosh‐style videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation
Patient or population: adults undergoing tracheal intubation Setting: hospital and out‐of‐hospital; international Intervention: Macintosh‐style videolaryngoscopy Comparison: direct laryngoscopy
Outcomes	Risk with direct laryngoscopy	Risk with Macintosh‐style videolaryngoscopy	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Failed intubation	Study population		RR 0.41 (0.26 to 0.65)	4615 (41 RCTs)	⊕⊕⊕⊝ Moderate^a
Failed intubation	65 per 1000	27 per 1000 (17 to 42)	RR 0.41 (0.26 to 0.65)	4615 (41 RCTs)	⊕⊕⊕⊝ Moderate^a
Hypoxaemia	Study population		RR 0.72 (0.52 to 0.99)	2127 (16 RCTs)	⊕⊕⊕⊝ Moderate^a
Hypoxaemia	106 per 1000	76 per 1000 (55 to 105)	RR 0.72 (0.52 to 0.99)	2127 (16 RCTs)	⊕⊕⊕⊝ Moderate^a
Successful first attempt	Study population		RR 1.05 (1.02 to 1.09)	7311 (42 RCTs)	⊕⊕⊝⊝ Low^a,b
Successful first attempt	813 per 1000	854 per 1000 (830 to 887)	RR 1.05 (1.02 to 1.09)	7311 (42 RCTs)	⊕⊕⊝⊝ Low^a,b
Oesophageal intubation	Study population		RR 0.51 (0.22 to 1.21)	2404 (14 RCTs)	⊕⊕⊝⊝ Low^a,c
Oesophageal intubation	29 per 1000	15 per 1000 (6 to 36)	RR 0.51 (0.22 to 1.21)	2404 (14 RCTs)	⊕⊕⊝⊝ Low^a,c
Dental trauma	Study population		RR 0.68 (0.16 to 2.89)	2297 (18 RCTs)	⊕⊝⊝⊝ Very low^a,d
Dental trauma	4 per 1000	2 per 1000 (1 to 10)	RR 0.68 (0.16 to 2.89)	2297 (18 RCTs)	⊕⊝⊝⊝ Very low^a,d
Cormack‐Lehane grade	Study population		RR 0.38 (0.29 to 0.48)	4368 (38 RCTs)	⊕⊕⊕⊝ Moderate^a,b	Data presented for frequency of Cormack‐Lehane grade 3 and 4 views
Cormack‐Lehane grade	196 per 1000	75 per 1000 (57 to 94)	RR 0.38 (0.29 to 0.48)	4368 (38 RCTs)	⊕⊕⊕⊝ Moderate^a,b
Time for tracheal intubation	See comment	See comment	‐	4061 (35 RCTs)	⊕⊝⊝⊝ Very low^a,e	High level of statistical heterogeneity between studies; therefore meta‐analysis not completed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aWe downgraded by one level for risk of performance bias due to the lack of blinding. ^bWe downgraded by one level for inconsistency because we noted considerable statistical heterogeneity. ^cWe downgraded by one level for imprecision because the confidence intervals indicated possible benefits as well as harms. ^dWe downgraded by two levels for imprecision because the frequency of events was small and the confidence intervals indicated possible benefits as well as harms. ^eWe downgraded by two levels for inconsistency because we noted extremely high statistical heterogeneity (I² = 96%).

Summary of findings 1. Macintosh‐style videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation

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Summary of findings 2. Hyperangulated videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Hyperangulated videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation
Patient or population: adults undergoing tracheal intubation Setting: hospital and out‐of‐hospital; international Intervention: hyperangulated videolaryngoscopy Comparison: direct laryngoscopy
Outcomes	Risk with direct laryngoscopy	Risk with hyperangulated videolaryngoscopy	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Failed intubation	Study population		RR 0.51 (0.34 to 0.76)	7146 (63 RCTs)	⊕⊕⊕⊝ Moderate^a
Failed intubation	56 per 1000	29 per 1000 (19 to 43)	RR 0.51 (0.34 to 0.76)	7146 (63 RCTs)	⊕⊕⊕⊝ Moderate^a
Hypoxaemia	Study population		RR 0.49 (0.22 to 1.11)	1691 (15 RCTs)	⊕⊕⊝⊝ Low^a,b
Hypoxaemia	44 per 1000	22 per 1000 (10 to 49)	RR 0.49 (0.22 to 1.11)	1691 (15 RCTs)	⊕⊕⊝⊝ Low^a,b
Successful first attempt	Study population		RR 1.03 (1.00 to 1.05)	8086 (66 RCTs)	⊕⊕⊝⊝ Low^a,c
Successful first attempt	854 per 1000	879 per 1000 (854 to 896)	RR 1.03 (1.00 to 1.05)	8086 (66 RCTs)	⊕⊕⊝⊝ Low^a,c
Oesophageal intubation	Study population		RR 0.39 (0.18 to 0.81)	1968 (14 RCTs)	⊕⊕⊕⊝ Moderate^a
Oesophageal intubation	26 per 1000	10 per 1000 (5 to 21)	RR 0.39 (0.18 to 0.81)	1968 (14 RCTs)	⊕⊕⊕⊝ Moderate^a
Dental trauma	Study population		RR 0.51 (0.16 to 1.59)	3497 (30 RCTs)	⊕⊝⊝⊝ Very low^a,d
Dental trauma	4 per 1000	2 per 1000 (1 to 7)	RR 0.51 (0.16 to 1.59)	3497 (30 RCTs)	⊕⊝⊝⊝ Very low^a,d
Cormack‐Lehane grade	Study population		RR 0.15 (0.10 to 0.24)	6058 (54 RCTs)	⊕⊕⊕⊝ Moderate^a,c	Data presented for frequency of Cormack‐Lehane grade 3 and 4 views
Cormack‐Lehane grade	189 per 1000	28 per 1000 (19 to 45)	RR 0.15 (0.10 to 0.24)	6058 (54 RCTs)	⊕⊕⊕⊝ Moderate^a,c
Time for tracheal intubation	see comment	see comment	‐	6644 (59 RCTs)	⊕⊝⊝⊝ Very low^a,e	High level of statistical heterogeneity between studies; therefore meta‐analysis not completed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aWe downgraded by one level for risk of performance bias due to the lack of blinding. ^bWe downgraded by one level for imprecision because the confidence intervals indicated possible benefits as well as harms. ^cWe downgraded by one level for inconsistency because we noted considerable statistical heterogeneity. ^dWe downgraded by two levels for imprecision because the frequency of events was small and the confidence intervals indicated possible benefits as well as harms. ^eWe downgraded by two levels for inconsistency because we noted extremely high statistical heterogeneity (I² = 99%).

Summary of findings 2. Hyperangulated videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation

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Summary of findings 3. Channelled videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation

Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Channelled videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation
Patient or population: adults undergoing tracheal intubation Setting: hospital and out‐of‐hospital; international Intervention: channelled videolaryngoscopy Comparison: direct laryngoscopy
Outcomes	Risk with direct laryngoscopy	Risk with channelled videolaryngoscopy	Relative effect (95% CI)	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Failed intubation	Study population		RR 0.43 (0.30 to 0.61)	5367 (53 RCTs)	⊕⊕⊕⊝ Moderate^a
Failed intubation	44 per 1000	19 per 1000 (13 to 27)	RR 0.43 (0.30 to 0.61)	5367 (53 RCTs)	⊕⊕⊕⊝ Moderate^a
Hypoxia	Study population		RR 0.25 (0.12 to 0.50)	1966 (15 RCTs)	⊕⊕⊕⊝ Moderate^a
Hypoxia	42 per 1000	10 per 1000 (5 to 21)	RR 0.25 (0.12 to 0.50)	1966 (15 RCTs)	⊕⊕⊕⊝ Moderate^a
Successful first attempt	Study population		RR 1.10 (1.05 to 1.15)	5210 (47 RCTs)	⊕⊕⊝⊝ Very low^a,b,c
Successful first attempt	826 per 1000	909 per 1000 (868 to 950)	RR 1.10 (1.05 to 1.15)	5210 (47 RCTs)	⊕⊕⊝⊝ Very low^a,b,c
Oesophageal intubation	Study population		RR 0.54 (0.17 to 1.75)	1756 (16 RCTs)	⊕⊕⊝⊝ Low^a,d
Oesophageal intubation	34 per 1000	19 per 1000 (6 to 60)	RR 0.54 (0.17 to 1.75)	1756 (16 RCTs)	⊕⊕⊝⊝ Low^a,d
Dental trauma	Study population		RR 0.52 (0.13 to 2.12)	2375 (29 RCTs)	⊕⊝⊝⊝ Very low^a,e
Dental trauma	3 per 1000	2 per 1000 (0 to 7)	RR 0.52 (0.13 to 2.12)	2375 (29 RCTs)	⊕⊝⊝⊝ Very low^a,e
Cormack‐Lehane grade	Study population		RR 0.14 (0.09 to 0.21)	3955 (40 RCTs)	⊕⊕⊕⊝ Moderate^a,b	Data presented for frequency of Cormack‐Lehane grade 3 and 4 views
Cormack‐Lehane grade	194 per 1000	27 per 1000 (17 to 41)	RR 0.14 (0.09 to 0.21)	3955 (40 RCTs)	⊕⊕⊕⊝ Moderate^a,b
Time for tracheal intubation	see comment	see comment	‐	5676 (57 RCTs)	⊕⊝⊝⊝ Very low^a,f	High level of statistical heterogeneity between studies; therefore meta‐analysis not completed
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomized controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
^aWe downgraded by one level for risk of performance bias due to the lack of blinding. ^bWe downgraded by one level for inconsistency because we noted considerable statistical heterogeneity. ^cWe downgraded by one level for suspicion of publication bias. ^dWe downgraded by one level for imprecision because the confidence intervals indicated possible benefits as well as harms. ^eWe downgraded by two levels for imprecision because the frequency of events was small and the confidence intervals indicated possible benefits as well as harms. ^fWe downgraded by two levels for inconsistency because we noted extremely high statistical heterogeneity (I² = 98%).

Summary of findings 3. Channelled videolaryngoscopy compared to direct laryngoscopy for adults undergoing tracheal intubation

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Comparison 1. Macintosh‐style VL versus DL

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Failed intubation Show forest plot	41	4615	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.26, 0.65]

1.2 Hypoxaemia Show forest plot	16	2127	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.52, 0.99]

1.3 Successful first attempt Show forest plot	42	7311	Risk Ratio (M‐H, Random, 95% CI)	1.05 [1.02, 1.09]

1.4 Oesophageal intubation Show forest plot	14	2404	Risk Ratio (M‐H, Random, 95% CI)	0.51 [0.22, 1.21]

1.5 Dental trauma Show forest plot	18	2297	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.16, 2.89]

1.6 Cormack‐Lehane (CL) grade Show forest plot	38	13104	Risk Ratio (M‐H, Random, 95% CI)	0.90 [0.81, 1.00]

1.6.1 Cormack‐Lehane 1	38	4368	Risk Ratio (M‐H, Random, 95% CI)	1.50 [1.39, 1.63]
1.6.2 Cormack‐Lehane 2	38	4368	Risk Ratio (M‐H, Random, 95% CI)	0.62 [0.51, 0.76]
1.6.3 Cormack‐Lehane 3‐4	38	4368	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.29, 0.48]
1.7 Time for tracheal intubation Show forest plot	35		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.8 Patient‐reported sore throat Show forest plot	17	1960	Risk Ratio (M‐H, Random, 95% CI)	0.85 [0.68, 1.07]

1.9 Number of attempts Show forest plot	31	6480	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.98, 1.08]

1.9.1 1 attempt	31	3240	Risk Ratio (M‐H, Random, 95% CI)	1.05 [1.01, 1.10]
1.9.2 2‐4 attempts	31	3240	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.46, 1.01]
1.10 Intubation Difficulty Scale (IDS) Show forest plot	4	801	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.88, 1.25]

1.10.1 IDS 0	4	267	Risk Ratio (M‐H, Random, 95% CI)	1.22 [0.87, 1.72]
1.10.2 IDS 1‐5	4	267	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.84, 1.28]
1.10.3 IDS > 5	4	267	Risk Ratio (M‐H, Random, 95% CI)	0.60 [0.25, 1.45]
1.11 POGO Score Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

1.12 Mortality Show forest plot	3	719	Risk Ratio (M‐H, Random, 95% CI)	1.01 [0.82, 1.24]

1.13 Subgroup analysis of failed intubation: airway difficulty Show forest plot	37	3925	Risk Ratio (M‐H, Random, 95% CI)	0.40 [0.23, 0.68]

1.13.1 Predicted, known or simulated difficulty	12	1393	Risk Ratio (M‐H, Random, 95% CI)	0.37 [0.19, 0.74]
1.13.2 No difficulty	25	2532	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.16, 1.10]

Comparison 1. Macintosh‐style VL versus DL

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Comparison 2. Hyperangulated VL versus DL

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Failed intubation Show forest plot	63	7146	Risk Ratio (M‐H, Random, 95% CI)	0.51 [0.34, 0.76]

2.2 Hypoxaemia Show forest plot	15	1691	Risk Ratio (M‐H, Random, 95% CI)	0.49 [0.22, 1.11]

2.3 Successful first attempt Show forest plot	66	8086	Risk Ratio (M‐H, Random, 95% CI)	1.03 [1.00, 1.05]

2.4 Oesophageal intubation Show forest plot	14	1968	Risk Ratio (M‐H, Random, 95% CI)	0.39 [0.18, 0.81]

2.5 Dental trauma Show forest plot	30	3497	Risk Ratio (M‐H, Random, 95% CI)	0.51 [0.16, 1.59]

2.6 Cormack‐Lehane (CL) grade Show forest plot	54	18174	Risk Ratio (M‐H, Random, 95% CI)	0.83 [0.74, 0.94]

2.6.1 Cormack‐Lehane 1	54	6058	Risk Ratio (M‐H, Random, 95% CI)	1.77 [1.56, 2.01]
2.6.2 Cormack‐Lehane 2	54	6058	Risk Ratio (M‐H, Random, 95% CI)	0.54 [0.46, 0.63]
2.6.3 Cormack‐Lehane 3‐4	54	6058	Risk Ratio (M‐H, Random, 95% CI)	0.15 [0.10, 0.24]
2.7 Time for tracheal intubation Show forest plot	59		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.8 Patient‐reported sore throat Show forest plot	31	3725	Risk Ratio (M‐H, Random, 95% CI)	0.81 [0.66, 1.00]

2.9 Number of attempts Show forest plot	50	11004	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.99, 1.04]

2.9.1 1 attempt	50	5502	Risk Ratio (M‐H, Random, 95% CI)	1.02 [1.00, 1.05]
2.9.2 2‐4 attempts	50	5502	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.66, 1.08]
2.10 Intubation Difficulty Scale (IDS) Show forest plot	10		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

2.10.1 IDS 0	10		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2.10.2 IDS 1‐5	10		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2.10.3 IDS > 5	10		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected
2.11 POGO Score Show forest plot	14		Mean Difference (IV, Random, 95% CI)	Subtotals only

2.12 Mortality Show forest plot	3	826	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.73, 1.79]

2.13 Subgroup analysis of failed intubation: airway difficulty Show forest plot	59	6607	Risk Ratio (M‐H, Random, 95% CI)	0.45 [0.30, 0.68]

2.13.1 Predicted, known or simulated difficulty	15	1520	Risk Ratio (M‐H, Random, 95% CI)	0.29 [0.17, 0.48]
2.13.2 No difficulty	44	5087	Risk Ratio (M‐H, Random, 95% CI)	0.64 [0.38, 1.06]

Comparison 2. Hyperangulated VL versus DL

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Comparison 3. Channelled VL versus DL

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Failed intubation Show forest plot	53	5367	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.30, 0.61]

3.2 Hypoxaemia Show forest plot	15	1966	Risk Ratio (M‐H, Random, 95% CI)	0.25 [0.12, 0.50]

3.3 Successful first attempt Show forest plot	47	5210	Risk Ratio (M‐H, Random, 95% CI)	1.10 [1.05, 1.15]

3.4 Oesophageal intubation Show forest plot	16	1756	Risk Ratio (M‐H, Random, 95% CI)	0.54 [0.17, 1.75]

3.5 Dental trauma Show forest plot	29	2375	Risk Ratio (M‐H, Random, 95% CI)	0.52 [0.13, 2.12]

3.6 Cormack‐Lehane (CL) grade Show forest plot	40	11865	Risk Ratio (M‐H, Random, 95% CI)	0.70 [0.58, 0.85]

3.6.1 Cormack‐Lehane 1	40	3955	Risk Ratio (M‐H, Random, 95% CI)	2.01 [1.75, 2.31]
3.6.2 Cormack‐Lehane 2	40	3955	Risk Ratio (M‐H, Random, 95% CI)	0.24 [0.17, 0.35]
3.6.3 Cormack‐Lehane 3‐4	40	3955	Risk Ratio (M‐H, Random, 95% CI)	0.14 [0.09, 0.21]
3.7 Time for tracheal intubation Show forest plot	57		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.8 Patient‐reported sore throat Show forest plot	18	1666	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.73, 1.14]

3.9 Number of attempts Show forest plot	38	8314	Risk Ratio (M‐H, Random, 95% CI)	1.05 [1.00, 1.10]

3.9.1 1 attempt	38	4157	Risk Ratio (M‐H, Random, 95% CI)	1.09 [1.04, 1.14]
3.9.2 2‐4 attempts	38	4157	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.33, 0.68]
3.10 Intubation Difficulty Scale (IDS) Show forest plot	16	3012	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.59, 1.19]

3.10.1 IDS 0	16	1004	Risk Ratio (M‐H, Random, 95% CI)	3.34 [2.43, 4.60]
3.10.2 IDS 1‐5	16	1004	Risk Ratio (M‐H, Random, 95% CI)	0.38 [0.27, 0.53]
3.10.3 IDS > 5	16	1004	Risk Ratio (M‐H, Random, 95% CI)	0.21 [0.12, 0.37]
3.11 POGO Score Show forest plot	5		Mean Difference (IV, Random, 95% CI)	Subtotals only

3.12 Subgroup analysis of failed intubation: airway difficulty Show forest plot	52	5287	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.29, 0.62]

3.12.1 Predicted, known or simulated difficulty	20	1433	Risk Ratio (M‐H, Random, 95% CI)	0.22 [0.10, 0.49]
3.12.2 No difficulty	32	3854	Risk Ratio (M‐H, Random, 95% CI)	0.53 [0.32, 0.88]

Comparison 3. Channelled VL versus DL

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Comparison 4. VL versus DL (all devices combined)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 Failed intubation Show forest plot	139	16228	Risk Ratio (M‐H, Random, 95% CI)	0.44 [0.35, 0.56]

4.2 Hypoxia Show forest plot	41	5434	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.44, 0.85]

4.3 Successful first attempt Show forest plot	138	19797	Risk Ratio (M‐H, Random, 95% CI)	1.05 [1.03, 1.07]

4.4 Oesophageal intubation Show forest plot	40	5768	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.29, 0.77]

4.5 Subgroup analysis of failed intubation: theatre versus non‐theatre Show forest plot	141	16450	Risk Ratio (M‐H, Random, 95% CI)	0.46 [0.36, 0.59]

4.5.1 Theatre	130	14604	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.32, 0.54]
4.5.2 Non‐theatre	11	1846	Risk Ratio (M‐H, Random, 95% CI)	0.68 [0.42, 1.09]
4.6 Subgroup analysis of failed intubation: obesity Show forest plot	133	14881	Risk Ratio (M‐H, Random, 95% CI)	0.43 [0.32, 0.56]

4.6.1 Obese	13	1085	Risk Ratio (M‐H, Random, 95% CI)	0.25 [0.13, 0.46]
4.6.2 Non‐obese	120	13796	Risk Ratio (M‐H, Random, 95% CI)	0.47 [0.35, 0.62]
4.7 Subgroup analysis of failed intubation: airway difficulty Show forest plot	132	14999	Risk Ratio (M‐H, Random, 95% CI)	0.42 [0.32, 0.54]

4.7.1 Predicted, known or simulated difficulty	42	4100	Risk Ratio (M‐H, Random, 95% CI)	0.32 [0.23, 0.44]
4.7.2 No difficulty	90	10899	Risk Ratio (M‐H, Random, 95% CI)	0.54 [0.38, 0.78]
4.8 Subgroup analysis of failed intubation: intubator experience Show forest plot	115	13095	Risk Ratio (M‐H, Random, 95% CI)	0.44 [0.34, 0.58]

4.8.1 Expert	98	10939	Risk Ratio (M‐H, Random, 95% CI)	0.41 [0.33, 0.50]
4.8.2 Non‐expert	17	2156	Risk Ratio (M‐H, Random, 95% CI)	0.62 [0.32, 1.18]

Comparison 4. VL versus DL (all devices combined)

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