IMPORTANCE: Advanced airway management is a critical component of cardiopulmonary resuscitation. The use of video laryngoscopy has become increasingly common, but their effect on intubation success and patient outcomes during cardiac arrest remains uncertain.
METHODS: We conducted a systematic review commissioned by the International Liaison Committee on Resuscitation (ILCOR) Advanced Life Support Task Force. Following PRISMA and ILCOR methodology, we searched PubMed, Embase, and Web of Science through October 2025 for randomized controlled trials (RCTs) and non-randomized studies comparing tracheal intubation with video laryngoscopy versus direct laryngoscopy during cardiac arrest. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 and Risk Of Bias In Non-randomized Studies of Interventions tools, and certainty of evidence was rated using Grading of Recommendations Assessment, Development and Evaluation methodology. Critical outcomes included first pass tracheal intubation success, overall tracheal intubation success, return of spontaneous circulation, survival, and survival with good neurologic outcome.
RESULTS: From 13,031 screened records, 16 studies (3 RCTs, 13 observational) were included. Across three RCTs enrolling 331 patients, very low-certainty evidence showed no difference between video and direct laryngoscopy for first-pass tracheal intubation success (RR 0.88, 95% CI 0.63-1.22) or overall intubation success (RR 1.00, 95% CI 0.90-1.12). Observational studies (n = 29,595) generally favored video laryngoscopy for both outcomes. Very low-certainty data from observational studies showed no consistent difference in return of spontaneous circulation (ROSC) or survival. Rates of esophageal intubation were lower with video laryngoscopy in all studies reporting this outcome (RCT: 4.3% vs 0%; observational data: 5.6% vs 1.4%).
CONCLUSIONS: Among adults undergoing tracheal intubation during cardiac arrest, use of video laryngoscopes may improve process outcomes such as first-pass success and reduced esophageal intubation, but there is no evidence of improved ROSC or patient survival. The overall certainty of evidence is very low.