Video or Direct Laryngoscopy for Doctors Still Learning to Intubate?
The debate over whether videolaryngoscopy should be the default for every intubation has gone on for years. Most of the strong trial data came from emergency departments and intensive care units. A large multicentre trial from Spain, published online November 9, 2026 in Anaesthesia, asked the question in a setting every anesthesiologist knows well: routine surgical intubations performed by residents with an attending close by.
The study
The VILARE trial, led by Taboada and colleagues across a network of Spanish teaching hospitals, randomized 1001 adults having surgery that required a breathing tube. For the first attempt, 501 were assigned to videolaryngoscopy and 500 to direct laryngoscopy. Every intubation was done by an anaesthesia resident under consultant supervision. The primary outcome was success on the first attempt.
First attempt success was 79.2% with the video laryngoscope and 70.2% with direct laryngoscopy, an absolute difference of 9.0 percentage points (95% CI 3.7 to 14.4). Glottic views were better with video (93.3% vs 80.8% reaching a modified Cormack-Lehane grade 2 or 2a view, as the authors reported it), residents rated the intubation as difficult less often (33.5% vs 47.2%), and procedural complications were less than half as common (7.7% vs 18.2%). Intubation time and the need for adjuncts such as a bougie were not meaningfully different.
How I read it
A nine point gain in first pass success is a real effect, and it fits with the larger trials in critically ill patients. Every extra attempt raises the chance of trauma, desaturation, and a case that quickly stops being routine. What I find most useful here is that these were ordinary elective patients and the operators were still learning. That is exactly the group where a better view should help most, and it did.
A few cautions. The operators could not be blinded, and difficulty ratings are subjective. The abstract does not break down the complications in detail, so I would want to see the full paper before drawing conclusions about specific harms. A first attempt success of around 70% with direct laryngoscopy also reflects early trainees, so the absolute gap is probably smaller in very experienced hands. Finally, direct laryngoscopy remains a skill worth keeping. Blood, secretions, or a failed screen can take video away in the moment you need it most.
What it means for practice here
For me the takeaway is less about residents and more about anyone who does not intubate every day. In Casper and across Wyoming, airways are often managed by clinicians who see far fewer intubations than a busy academic anesthesiologist, sometimes in places where help is a long way off. This trial adds to the case for having a video laryngoscope readily available and making it the first choice for most intubations, while still practicing direct laryngoscopy often enough that it stays sharp. The goal is the same as always: get the tube in safely on the first try.
Source
- Taboada M, Bermúdez M, Fernández J, et al.; VILARE trial Investigators Group. Videolaryngoscopy vs. direct laryngoscopy for tracheal intubation by anaesthesia resident doctors (VILARE): a pragmatic multicentre randomised trial. Anaesthesia. Published online November 9, 2026. doi:10.1111/anae.70456. Article · PubMed
This post is clinician commentary for educational discussion. It is not medical advice for any reader's personal care. Anesthesia and perioperative decisions should be made with the treating clinician based on the individual patient's circumstances.