Videolaryngoscopy Increases First-Attempt Success for Double-Lumen Tube Intubation

Optimizing Lung Isolation in Thoracic Anesthesia

Achieving reliable lung isolation remains a technically demanding task in thoracic anesthesia because double-lumen tubes (specialized endotracheal tubes designed to ventilate each lung independently) are significantly larger and more rigid than standard tubes [1, 2]. While videolaryngoscopy is now standard for single-lumen tubes, its routine application for double-lumen tubes has historically lacked high-level evidence, with previous meta-analyses showing statistically similar first-attempt success rates between digital visualization and direct laryngoscopy [3, 4]. Clinicians frequently encounter poor glottic exposure during these procedures and may require external laryngeal manipulation (applying manual pressure to the thyroid cartilage to improve the view of the vocal cords), a maneuver that can increase the risk of airway trauma [3, 2]. Current consensus documents from the European Association of Cardiothoracic Anaesthesiology and Intensive Care suggest that while digital visualization may improve the glottic view, more robust data are required to justify its routine adoption in clinical practice [1, 5]. A new multicenter randomized trial now provides high-level evidence regarding the efficacy of videolaryngoscopy for double-lumen tube placement in patients undergoing thoracic surgery, offering clear guidance for anesthesiologists seeking to minimize airway complications [6].

Multicenter Trial Design and Primary Success Rates

To address this clinical gap, researchers conducted a multicenter, randomized trial across four Spanish hospitals to evaluate the efficacy of different intubation techniques for thoracic surgery. The study enrolled 916 adult patients scheduled for surgical procedures requiring lung isolation, which is the selective ventilation of one lung while the other is deflated to facilitate surgical access. The investigators assigned these participants to receive double-lumen tube intubation using either videolaryngoscopy (which utilizes a digital camera-equipped blade to visualize the glottis on a monitor) or traditional direct laryngoscopy. The primary outcome of the trial was successful intubation on the first attempt, a critical metric for reducing airway trauma, hypoxia, and physiological stress during anesthesia induction. Among the 458 participants in the videolaryngoscopy group, successful first-attempt intubation occurred in 388 patients (84.7%). In contrast, 352 of the 458 participants (76.9%) in the direct laryngoscopy group achieved first-attempt success. This represents an absolute risk difference of 7.9 percentage points (95% confidence interval [CI] 2.8 to 12.8; P=0.003), establishing a statistically significant advantage for digital visualization in achieving rapid airway control with these complex tubes. For practicing anesthesiologists, this translates to a higher likelihood of securing the airway smoothly on the first try, thereby minimizing patient risk.

Visual Clarity and Procedural Ease

Beyond the primary success rate, the researchers evaluated several secondary outcomes to characterize the clinical utility of each technique, including glottic visualization (the clinician's ability to clearly see the vocal cords and laryngeal opening) and procedural ease. The study found that good glottic visualization was achieved in 429 participants (93.7%) in the videolaryngoscopy group compared to 370 participants (80.8%) in the direct laryngoscopy group. This resulted in an absolute risk difference of 12.9 percentage points (95% CI 8.6% to 17.1%; P<0.001), demonstrating that digital visualization provides a more consistent view of the airway anatomy during the placement of bulky double-lumen tubes. This improved visibility translated directly into a more straightforward procedure for the anesthesia teams. Videolaryngoscopy was associated with a higher rate of easy intubation, occurring in 81.9% of cases compared to 68.6% in the direct laryngoscopy group (absolute risk difference 13.3 percentage points; 95% CI 7.8% to 18.8%; P<0.001). This increased ease of use is closely linked to the stability of the visual field. The researchers noted that loss of glottic view occurred in only 4.4% of the videolaryngoscopy group versus 21.8% in the direct laryngoscopy group (P<0.001). Furthermore, the use of digital screens reduced the need for external airway manipulation, such as applying physical pressure to the neck to force the vocal cords into view. This maneuver was required in 28.6% of videolaryngoscopy cases compared to 40.6% of direct laryngoscopy cases (P<0.001), suggesting that videolaryngoscopy can reduce the physical force needed to secure the airway.

Safety Profiles and Procedural Efficiency

The use of videolaryngoscopy also demonstrated specific safety advantages regarding the accurate placement of the double-lumen tube. The researchers found that videolaryngoscopy reduced the incidence of esophageal intubation, a potentially severe complication, which occurred in 1.7% of the videolaryngoscopy group compared to 4.6% in the direct laryngoscopy group (P=0.014). Beyond avoiding the esophagus, the digital approach improved the accuracy of the final tube location within the airway. Specifically, videolaryngoscopy reduced double-lumen tube malposition (the incorrect placement of the tube within the tracheobronchial tree), with rates of 7.6% in the videolaryngoscopy group versus 12.4% in the direct laryngoscopy group (P=0.016). For the surgical team, fewer malpositions mean less time spent repositioning the tube with a flexible bronchoscope and fewer interruptions during the operation. Despite the added steps of setting up digital equipment, the study found that intubation time was similar between the videolaryngoscopy and direct laryngoscopy groups, indicating that the transition to digital visualization does not introduce procedural delays in the operating room. Furthermore, the overall safety profile remained consistent across both cohorts, as other peri-intubation complications were similar between groups. These findings indicate that while videolaryngoscopy offers targeted improvements in placement accuracy and visualization, it maintains a comparable baseline of safety for the broader range of complications encountered during thoracic surgery, supporting its routine use for double-lumen tube placement.

References

1. Granell M, Vanpeteghem C, Mourisse J, et al. Airway Management in Thoracic Anesthesia: EACTAIC Consensus Document. Journal of Cardiothoracic and Vascular Anesthesia. 2025. doi:10.1053/j.jvca.2025.11.004

2. Yao W, Li M, Zhang C, Luo A. Recent Advances in Videolaryngoscopy for One-Lung Ventilation in Thoracic Anesthesia: A Narrative Review. Frontiers in Medicine. 2022. doi:10.3389/fmed.2022.822646

3. Karczewska K, Białka S, Smereka J, et al. Efficacy and Safety of Video-Laryngoscopy versus Direct Laryngoscopy for Double-Lumen Endotracheal Intubation: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2021. doi:10.3390/jcm10235524

4. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Canadian Journal of Anesthesia/Journal canadien d anesthésie. 2021. doi:10.1007/s12630-021-02008-z

5. Grandjean C, Casso G, Noirez L, Granell M, Savoldelli GL, Schoettker P. Innovations to Improve Lung Isolation Training for Thoracic Anesthesia: A Narrative Review. Journal of Clinical Medicine. 2024. doi:10.3390/jcm13071848

6. Fernández J, Francisco C, Seoane-Pillado T, et al. Videolaryngoscopy versus direct laryngoscopy for double-lumen tube intubation: the DOuble-Lumen intubation with VIdeolaryngoscopy (DOLVI) multicentre randomised trial.. British journal of anaesthesia. 2026. doi:10.1016/j.bja.2026.02.048