Invited Commentary 

Anesthesiology

A New Trial to Better Define the Role of Video Laryngoscopes

Luc Desmedt, Jean-Baptiste Lascarro

JAMA Netw Open 2026;9;(8):e2625982. doi:10.1001/jamanetworkopen.2026.25982

Endotracheal intubation is among the most frequently performed high-stakes procedures in anesthesiology. In the operating room (OR), it is usually planned, controlled, and uneventful; outside the OR, it may occur in critically ill patients with little margin for error. In both settings, success depends not only on technical skill but also on preparation, device choice, rescue planning, and team coordination.

Schmid et al¹ report the results of the Conventional vs Video-Assisted Laryngoscopy for Perioperative Endotracheal Intubation (COVALENT) trial, a pragmatic multicenter randomized clinical trial comparing direct laryngoscopy, Macintosh-style video laryngoscopy, and hyperangulated video laryngoscopy for perioperative tracheal intubation. Among 2423 patients included in the modified intention-to-treat analysis, the first-pass success rate was 78.2% for direct laryngoscopy, 82.9% for Macintosh-style video laryngoscopy, and 87.6% for hyperangulated video laryngoscopy. Both video laryngoscopy approaches were superior to direct laryngoscopy, and hyperangulated video laryngoscopy was superior to Macintosh-style video laryngoscopy for first-pass success. Time to first positive capnography (defined as successful intubation) and incidence of desaturation below 90% were similar across groups, whereas intermittent ventilation was more frequent after direct laryngoscopy.

Schmid et al¹ conducted a large trial addressing a question that remains relevant despite the rapid diffusion of video laryngoscopy into daily practice. Video laryngoscopy initially entered clinical practice as a rescue technique for anticipated or encountered difficult airways, but it is now increasingly used as a first-line device. Randomized clinical trials, implementation studies, and meta-analyses have consistently shown that video laryngoscopy improves glottic visualization and, in many settings, increases first-pass success.^2,3 The COVALENT trial adds to this evidence through its pragmatic international design, inclusion of unselected surgical patients, and direct comparison of not only direct and video laryngoscopy but also 2 major types of video laryngoscope in the same trial.

First-pass success is objective, clinically intuitive, and aligned with the central goal of airway management: securing the airway while minimizing repeated instrumentation. However, first-pass success remains a procedural outcome rather than a patient-centered end point.⁴ In the COVALENT trial,¹ improved first-pass success did not translate into a clear reduction in mechanical complications (dental or lip injuries). This finding contrasts with intensive care unit and emergency airway management, where repeated attempts are more directly associated with hypoxemia, hemodynamic collapse, and adverse outcomes; even those outcomes need to be pooled to significantly differ from outcomes of video laryngoscopy.⁵ In routine adult anesthesia, first-pass success should therefore be interpreted as an important surrogate rather than definitive proof that clinically important complications will necessarily be reduced.

This distinction has economic implications for a procedure that is likely performed tens of millions of times each year worldwide. Universal video laryngoscopy requires investment that may be justified if fewer attempts reduce rescue techniques, supervision burden, airway trauma, or rare catastrophic complications. Yet the economic case remains incompletely established for unselected OR intubations, precisely because the outcome most consistently improved is first-pass success. Cost-effectiveness studies should account for device type, reusable vs disposable blades, stylet use, OR volume, downstream complications, and availability in and out of the OR.^6,7

Several design and implementation issues in the COVALENT trial¹ deserve attention. First, the screening and selection process is informative. Nearly 30 000 patients were screened, but only 2532 were randomized. More granular information on excluded patients would help readers determine whether anesthesia clinicians withheld enrollment because of clinical concerns about random allocation to any of the airway devices. If so, exclusions may be less a limitation than a marker of how deeply video laryngoscopy has already been integrated into contemporary anesthetic practice, consistent with calls for universal implementation strategies.⁶ Conversely, 478 of the 2532 patients (18.9%) had a Mallampati score of 3 or 4, corresponding to a subgroup in whom first-line video laryngoscopy strategy is already considered standard practice. Including these patients may have favored the video laryngoscopy groups and amplified the intervention effect.

Second, stylet use was highly unbalanced: 34.9% in the direct laryngoscopy group, 72.5% in the Macintosh-style video laryngoscopy group, and 95.7% in the hyperangulated video laryngoscopy group. The absence of adjuncts (ie, stylet or bougie) was a limitation of the first trial on video laryngoscopy,⁸ and data have questioned the role of restricted glottis view in successful intubation using video laryngoscopy.⁹ Those elements question the respective role of video laryngoscopy, blade, stylet, or bougie in the benefit observed. It also means that the trial compared intubation strategies rather than isolated devices.

Third, the devices used in the trial were not evenly distributed across manufacturers; Storz C-MAC devices represented the majority of video laryngoscopes in both video laryngoscopy arms. The trial was not designed to compare manufacturers, and its pragmatic approach improved external validity. Still, the results should not be overgeneralized to all video laryngoscopes, particularly channeled devices.¹⁰

The COVALENT trial¹ strengthens the argument that video laryngoscopy should become the default approach for many routine perioperative intubations. The next questions are more specific and more clinically useful: which video laryngoscope, with which adjunct, at what cost, and for what objectives? The respective roles of alternative devices (eg, supraglottic airway devices) and video laryngoscopy, which now holds a prominent place, need to be better defined.