Videolaryngoscopy Versus Direct Laryngoscopy in Predicted Difficult Airways: A Comparative Study

Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 729 International Journal of Medical and Pharmaceutical Research Online ISSN-2958-3683 | Print ISSN-2958-3675 Frequency: Bi-Monthly Available online on: https://ijmpr.in/ Original Article Videolaryngoscopy Versus Direct Laryngoscopy in Predicted Difficult Airways: A Comparative Study Dr. Prathap Pancheti1, Dr.kamidi.Rishika2, Dr.Kamidi.Varun3 1Assistant Professor, Dept of Anesthesiology and Critical Care Medicine, Konaseema Institute of Medical Sciences and Research Foundation 2Senior resident, Dept of Anesthesiology. 3MD Pathology, Associate Professor, Gayatri Vidya Parishad Institute of Health Care and Medical Technology A B S T R A C T Corresponding Author: Dr. Prathap Pancheti Assistant Professor, Dept of Anesthesiology and Critical Care Medicine, Konaseema Institute of Medical Sciences and Research Foundation Received: 14-10-2025 Accepted: 16-11-2025 Available online: 26-11-2025 Background: Difficult airway management remains a critical challenge in anaesthesia practice, with failed intubation being a leading cause of anaesthesiarelated morbidity and mortality. Videolaryngoscopy has emerged as a promising alternative to conventional direct laryngoscopy, offering enhanced glottic visualization through video technology. However, its superiority in predicted difficult airway scenarios requires robust evidence from well-designed comparative studies. This study aimed to compare the efficacy and safety of videolaryngoscopy versus direct laryngoscopy in patients with predicted difficult airways undergoing elective surgical procedures. Methods: This prospective comparative study was conducted at Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, from February 2024 to June 2025. A total of 500 adult patients with predicted difficult airways, as identified by preoperative airway assessment scores, were allocated to either the videolaryngoscopy group (n=250) or the direct laryngoscopy group (n=250) based on alternate allocation method. Primary outcomes included firstattempt intubation success rate, time to intubation, and Cormack-Lehane grading. Secondary outcomes encompassed hemodynamic parameters, intubation-related complications, and overall intubation difficulty score. Results: The videolaryngoscopy group demonstrated significantly higher firstattempt intubation success rates compared to direct laryngoscopy (88.4% vs 72.8%, p<0.001). Mean intubation time was comparable between groups (42.3±12.6 seconds vs 45.8±15.2 seconds, p=0.065). Videolaryngoscopy provided superior glottic visualization with significantly better Cormack-Lehane grades (Grade I-II: 84.0% vs 61.6%, p<0.001). The incidence of intubation-related complications, including mucosal trauma and dental injury, was significantly lower in the videolaryngoscopy group (6.4% vs 14.8%, p=0.003). Hemodynamic stability was better maintained with videolaryngoscopy. Conclusion: Videolaryngoscopy significantly improves first-attempt intubation success rates and reduces complications in patients with predicted difficult airways compared to conventional direct laryngoscopy. The enhanced glottic visualization provided by videolaryngoscopy translates into improved patient safety outcomes. These findings support the integration of videolaryngoscopy as the preferred intubation technique for managing predicted difficult airways in routine anaesthesia practice. Copyright© International Journal of Medical and Pharmaceutical Research Keywords:Videolaryngoscopy, Direct laryngoscopy, Difficult airway, Intubation, Cormack-Lehane grade, Comparative study. INTRODUCTION Airway management is a fundamental and critical skill in anaesthesia practice, with successful endotracheal intubation being essential for patient safety during general anaesthesia and emergency situations. Despite advances in airway Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 730 management techniques and devices, difficult intubation continues to be a significant clinical challenge, occurring in approximately 5-8% of routine anaesthetic procedures and contributing substantially to anaesthesia-related morbidity and mortality [1,2]. Failed intubation, defined as the inability to successfully place an endotracheal tube after multiple attempts, represents one of the leading causes of major anaesthetic complications, potentially resulting in hypoxic brain injury, cardiac arrest, and death [3]. The prediction of difficult airways has been extensively studied, with various anatomical and clinical factors identified as risk predictors. The modified Mallampati classification, thyromental distance, sternomental distance, mouth opening, and neck mobility assessment constitute the cornerstone of preoperative airway evaluation [1,4]. These bedside screening tests, when used in combination, enhance the sensitivity and specificity of difficult airway prediction, allowing anaesthesiologists to formulate appropriate management strategies and prepare necessary equipment and expertise. However, even with meticulous preoperative assessment, unexpected difficult airways continue to challenge clinicians, highlighting the need for improved intubation techniques and equipment. Direct laryngoscopy, first described by Chevalier Jackson in 1913, has remained the gold standard technique for endotracheal intubation for over a century. This conventional method requires alignment of the oral, pharyngeal, and laryngeal axes through head extension and elevation to achieve direct line-of-sight visualization of the glottic opening. While direct laryngoscopy has proven effective for routine intubations, it has several inherent limitations, particularly in patients with difficult airways [2]. These limitations include restricted visualization in patients with limited mouth opening, cervical spine immobility, anterior laryngeal anatomy, or obesity. Furthermore, the technique requires significant skill acquisition, may cause hemodynamic instability due to sympathetic stimulation, and carries risks of dental trauma and soft tissue injury. The introduction of videolaryngoscopy represents a paradigm shift in airway management, offering indirect visualization of the glottic opening through a video camera mounted on the laryngoscope blade. This technology eliminates the requirement for direct line-of-sight visualization by providing an enlarged, high-resolution image of the laryngeal inlet on an external monitor [5]. Videolaryngoscopes are available in various designs, including channeled devices that guide endotracheal tube placement and non-channeled devices that require manual tube manipulation. The enhanced visualization provided by videolaryngoscopy theoretically offers several advantages over direct laryngoscopy, including improved Cormack-Lehane grades, reduced intubation attempts, decreased cervical spine movement, and potential educational benefits for training junior anaesthesiologists. Multiple systematic reviews and meta-analyses have evaluated the comparative efficacy of videolaryngoscopy versus direct laryngoscopy, with generally favorable results for videolaryngoscopy in terms of first-attempt success rates and glottic visualization [6,7]. However, several studies have reported conflicting results regarding intubation time, with some demonstrating prolonged intubation duration with videolaryngoscopy, particularly among less experienced operators. Additionally, concerns have been raised about the learning curve associated with videolaryngoscopy and the potential for complications related to excessive force application due to the indirect view. The evidence supporting videolaryngoscopy specifically in predicted difficult airway scenarios remains heterogeneous, with many studies limited by small sample sizes, varying definitions of difficult airways, and differences in operator experience and videolaryngoscope models [8]. Furthermore, most existing literature originates from Western populations, with limited representation from South Asian populations who may have distinct anatomical characteristics affecting airway management. The Indian population, characterized by relatively shorter stature, different craniofacial morphology, and higher prevalence of conditions such as rheumatoid arthritis affecting cervical spine mobility, may present unique challenges in airway management that warrant specific investigation. Previous studies have predominantly focused on emergency department settings or included mixed populations of both predicted easy and difficult airways, potentially diluting the observable treatment effects in the difficult airway subgroup. Additionally, many trials have been underpowered to detect clinically meaningful differences in important secondary outcomes such as complication rates and hemodynamic stability [9]. There exists a critical need for adequately powered comparative studies specifically targeting patients with predicted difficult airways to establish definitive evidence for clinical practice guidelines and recommendations. The selection of appropriate intubation technique in predicted difficult airways has significant implications for patient safety, healthcare resource utilization, and training programs. Videolaryngoscopy equipment represents a substantial capital investment for healthcare institutions, and the cost-effectiveness of routine videolaryngoscopy use in predicted difficult airways requires evaluation through rigorous clinical studies demonstrating clear clinical benefits [10]. Furthermore, understanding the comparative performance characteristics of different intubation techniques is essential for developing evidence-based difficult airway management algorithms and educational curricula for anaesthesia trainees. Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 731 Given the limited high-quality evidence from adequately powered comparative studies evaluating videolaryngoscopy and direct laryngoscopy specifically in predicted difficult airways, and considering the unique population characteristics in the Indian subcontinent, this study was designed to provide robust comparative effectiveness data. The investigation aimed to evaluate multiple clinically relevant outcomes including first-attempt intubation success, visualization quality, intubation time, hemodynamic responses, and complication profiles. By focusing exclusively on patients identified preoperatively as having predicted difficult airways based on validated assessment tools, this research addresses a critical gap in the existing literature and provides evidence to inform clinical decision-making in this high-risk patient population. This prospective comparative study was conducted to comprehensively compare the efficacy and safety of videolaryngoscopy versus direct laryngoscopy in patients with predicted difficult airways undergoing elective surgical procedures at a tertiary care teaching hospital in South India. The findings of this study have the potential to significantly influence airway management practices, institutional protocols, and training approaches for managing difficult airways in the perioperative setting. AIMS AND OBJECTIVES The primary aim of this comparative study was to evaluate the efficacy of videolaryngoscopy versus direct laryngoscopy in patients with predicted difficult airways undergoing elective surgical procedures requiring general anaesthesia with endotracheal intubation. The study was designed to compare multiple dimensions of intubation performance, safety parameters, and clinical outcomes to provide comprehensive evidence for clinical decision-making in difficult airway management. The primary objective was to determine and compare the first-attempt intubation success rate in patients with predicted difficult airways when managed with videolaryngoscopy compared to conventional direct laryngoscopy. First-attempt success was defined as successful placement of the endotracheal tube in the trachea with appropriate position confirmation using capnography within a single laryngoscopy attempt without the need for removal of the laryngoscope blade or change in technique. This outcome was selected as the primary endpoint because first-attempt success is strongly correlated with patient safety, reduces the risk of desaturation, minimizes airway trauma, and represents a clinically meaningful measure of intubation efficacy. The secondary objectives encompassed a comprehensive evaluation of multiple performance and safety parameters. The study aimed to compare the time required for successful intubation between the two techniques, measured from insertion of the laryngoscope blade between the teeth to confirmation of correct endotracheal tube placement by capnography. Intubation time represents an important clinical parameter as prolonged intubation attempts increase the risk of hypoxemia and hemodynamic instability. The investigation also sought to assess the quality of glottic visualization achieved with each technique using the Cormack-Lehane classification system, which grades the laryngeal view from Grade I (full view of glottis) to Grade IV (neither glottis nor epiglottis visible). Superior glottic visualization theoretically facilitates easier tube placement and reduces traumatic complications. Additional secondary objectives included evaluation of the number of intubation attempts required for successful airway securement, assessment of the need for optimization maneuvers such as external laryngeal manipulation or use of stylet, and documentation of the overall intubation difficulty using validated difficulty scoring systems. The study aimed to compare hemodynamic parameters including heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure at baseline, immediately after intubation, and at regular intervals following intubation to assess the cardiovascular stress response associated with each intubation technique. The research also sought to document and compare the incidence and severity of intubation-related complications between the two groups. These complications included mucosal trauma evidenced by blood on the laryngoscope blade or endotracheal tube, dental injury, lip trauma, sore throat, hoarseness, and any episodes of significant desaturation defined as peripheral oxygen saturation below 90% during the intubation process. The occurrence of failed intubation necessitating alternative airway management strategies was also recorded to provide complete safety data. Furthermore, the study aimed to evaluate operator-reported ease of intubation using visual analog scales and to document any technical difficulties encountered during the intubation process. This subjective assessment provided additional insights into the practical aspects of using each technique in clinical practice. The investigation also sought to identify patient-specific and anatomical factors that might predict differential success rates between videolaryngoscopy and direct laryngoscopy, potentially informing individualized airway management algorithms. The comprehensive nature of these objectives allowed for thorough evaluation of videolaryngoscopy performance in the specific population of patients with predicted difficult airways, addressing critical gaps in existing literature and providing evidence to support evidencebased clinical practice guidelines for difficult airway management. Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 732 MATERIALS AND METHODS Study Design and Setting This prospective, single-center, comparative study was conducted in the Department of Anaesthesiology at Konaseema Institute of Medical Sciences and Research Foundation (KIMS), Amalapuram, Andhra Pradesh, India, over a period of 16 months from February 2024 to June 2025. The study protocol was approved by the Institutional Ethics Committee prior to commencement. Written informed consent was obtained from all participants after detailed explanation of the study procedures, potential risks, and benefits in their preferred language. Sample Size Calculation The sample size was calculated based on previous literature reporting first-attempt intubation success rates of approximately 95% with videolaryngoscopy and 80% with direct laryngoscopy in difficult airway populations. Using these estimates, with an alpha error of 0.05 and power of 90%, the calculated sample size was 218 patients per group. Accounting for potential dropouts and protocol violations estimated at 15%, the final sample size was determined to be 250 patients per group, totaling 500 patients. This adequately powered design ensured sufficient statistical power to detect clinically meaningful differences in the primary outcome while also allowing for robust analysis of secondary outcomes and subgroup analyses. Study Population and Recruitment The study population comprised adult patients aged 18-65 years scheduled for elective surgical procedures under general anaesthesia requiring endotracheal intubation at KIMS, Amalapuram. All patients underwent comprehensive preoperative airway assessment during the pre-anaesthetic evaluation conducted 24-48 hours before surgery. Patients were identified as having predicted difficult airways based on the presence of two or more of the following criteria: modified Mallampati class III or IV, thyromental distance less than 6.5 cm, sternomental distance less than 12.5 cm, mouth opening less than 3 cm, limited neck extension (less than 80 degrees), presence of prominent upper incisors, or history of previous difficult intubation. This multiparametric approach to difficult airway prediction enhanced the specificity and clinical relevance of the study population. Inclusion and Exclusion Criteria Patients were eligible for inclusion if they were adults aged 18-65 years with American Society of Anesthesiologists (ASA) physical status classification I-III, scheduled for elective surgery requiring general anaesthesia with endotracheal intubation, and identified as having predicted difficult airway based on the aforementioned criteria. Patients provided written informed consent and had no contraindications to either study intervention. Exclusion criteria were carefully defined to ensure patient safety and data quality. Patients were excluded if they required emergency surgery precluding adequate time for consent and allocation processes, had known or suspected cervical spine injury or instability requiring specific positioning precautions, presented with active upper airway infection, tumors, or significant anatomical abnormalities such as maxillofacial trauma, required rapid sequence intubation due to full stomach or increased aspiration risk, had severe cardiorespiratory compromise with anticipated difficult oxygenation, possessed known allergy to anaesthetic medications used in the study protocol, were pregnant or breastfeeding, had body mass index exceeding 40 kg/m², or declined participation in the study. Group Allocation Eligible patients who provided informed consent were allocated to either the videolaryngoscopy group or the direct laryngoscopy group using an alternate allocation method. Patients were sequentially assigned to groups based on their order of recruitment, with odd-numbered patients allocated to the videolaryngoscopy group and even-numbered patients allocated to the direct laryngoscopy group. This systematic allocation approach ensured equal group sizes and facilitated operational implementation while maintaining comparability of baseline characteristics between groups. Standardization of Anaesthesia Protocol To minimize confounding variables and ensure consistency across both study groups, a standardized anaesthesia protocol was implemented for all patients. Patients were kept nil per oral for at least 8 hours for solids and 2 hours for clear fluids according to standard fasting guidelines. Upon arrival in the operating room, standard monitoring was established including electrocardiography, non-invasive blood pressure measurement, pulse oximetry, and capnography. Intravenous access was secured, and baseline vital signs were recorded. Pre-oxygenation was performed with 100% oxygen for 3 minutes via face mask with appropriate seal. Anaesthesia induction was accomplished using a standardized regimen consisting of intravenous fentanyl 2 mcg/kg, propofol 2-2.5 mg/kg titrated to loss of consciousness, and rocuronium bromide 0.9 mg/kg to facilitate neuromuscular blockade. Adequacy of muscle relaxation was confirmed by absence of response to train-of-four stimulation before attempting laryngoscopy. Mask ventilation was performed for 3 minutes following neuromuscular blockade administration to ensure complete muscle relaxation and optimal intubation conditions. Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 733 Intervention Procedures For patients allocated to the direct laryngoscopy group, intubation was performed using a standard Macintosh laryngoscope with an appropriate blade size (typically size 3 for women and size 4 for men) selected based on patient anatomy. The laryngoscope was inserted along the right side of the tongue, advancing the blade to the vallecula, and gentle anterior and cephalad lifting force was applied to expose the glottic opening. External laryngeal manipulation (BURP maneuver - Backward, Upward, Rightward Pressure) was permitted when necessary to optimize glottic visualization. An appropriate sized endotracheal tube (7.0-7.5 mm internal diameter for women, 8.0-8.5 mm for men) was advanced through the vocal cords under direct visualization. For patients allocated to the videolaryngoscopy group, intubation was performed using a C-MAC videolaryngoscope (Karl Storz, Germany) with a standard Macintosh-type blade design appropriate for patient size. The videolaryngoscope blade was inserted similarly to direct laryngoscopy, but visualization was achieved by viewing the integrated monitor screen rather than direct line-of-sight. The blade was advanced to identify anatomical landmarks including the epiglottis and vocal cords on the video display. The endotracheal tube was advanced using a pre-formed stylet to facilitate passage through the glottic opening, with tube advancement guided by the video image. The stylet was removed once the tube passed through the vocal cords, and the tube was advanced to the appropriate depth. Primary and Secondary Outcome Measures The primary outcome measure was first-attempt intubation success rate, defined as successful placement and confirmation of the endotracheal tube position within a single laryngoscopy attempt without removal of the laryngoscope blade from the patient's mouth. Success was confirmed by presence of end-tidal carbon dioxide on capnography, bilateral chest expansion, and auscultation of bilateral breath sounds with absence of epigastric sounds. Secondary outcome measures included total intubation time measured in seconds from insertion of the laryngoscope blade between the teeth until confirmation of successful tube placement by capnography, Cormack-Lehane grade of glottic visualization (Grade I: complete glottic opening visible, Grade II: partial glottic opening visible, Grade III: only epiglottis visible, Grade IV: neither glottis nor epiglottis visible), total number of intubation attempts required (maximum three attempts permitted before declaring failed intubation), and requirement for optimization maneuvers including external laryngeal manipulation, use of bougie, or stylet adjustment. Hemodynamic parameters including heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure were recorded at baseline before induction, immediately after intubation (0 minutes), and at 3, 5, and 10 minutes post-intubation. The intubation difficulty scale score was calculated for each patient based on a validated seven-variable scoring system incorporating number of attempts, number of operators, number of alternative techniques, CormackLehane grade, lifting force required, external laryngeal pressure requirement, and vocal cord mobility. Complications were systematically documented and classified as immediate or delayed. Immediate complications included mucosal trauma evidenced by blood on equipment, dental injury, lip or tongue trauma, episodes of desaturation (SpO2 <90%), significant hemodynamic instability defined as greater than 20% change from baseline values, laryngospasm, and esophageal intubation. Delayed complications assessed during post-anaesthesia care unit stay and at 24 hours post-operatively included sore throat graded on a 0-10 numerical rating scale, hoarseness, dysphagia, and any other airway-related symptoms. Management of Failed Intubation A standardized failed intubation protocol was established to ensure patient safety. Failed intubation was defined as inability to successfully intubate after three attempts with the allocated device. In case of failed intubation, the primary operator immediately called for assistance, maintained oxygenation via face mask or supraglottic airway device, and prepared for alternative airway management strategies. The protocol allowed for use of the alternative study device, awake fiberoptic intubation, or other advanced airway techniques as clinically appropriate. All cases of failed intubation were documented in detail, and the decision-making process was recorded for comprehensive safety analysis. Data Collection and Quality Control Dedicated research personnel trained in standardized data collection procedures recorded all study variables using predesigned case record forms. Data collected included demographic information (age, sex, weight, height, body mass index), airway assessment parameters (Mallampati class, thyromental distance, sternomental distance, inter-incisor distance, neck mobility), ASA physical status classification, surgical procedure details, all primary and secondary outcome measures, and any adverse events or protocol deviations. Quality control measures included regular monitoring of data completeness and accuracy, random verification of 10% of recorded data against source documents, and weekly research team meetings to address any questions or inconsistencies. All laryngoscopies and intubations were performed by experienced consultant anaesthesiologists with minimum 5 years of post-residency experience and documented proficiency in both direct laryngoscopy and videolaryngoscopy techniques. Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 734 This standardization of operator expertise minimized learning curve effects and ensured valid comparison of the two techniques. Statistical Analysis Statistical analysis was performed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were calculated for all variables, with continuous data presented as mean ± standard deviation for normally distributed variables and median with interquartile range for non-normally distributed variables. Categorical data were presented as frequencies and percentages. Baseline characteristics were compared between groups using independent samples t-test for continuous normally distributed variables, Mann-Whitney U test for non-normally distributed continuous variables, and chi-square test or Fisher's exact test for categorical variables. The primary outcome (first-attempt success rate) was analyzed using chisquare test, with results presented as proportions with 95% confidence intervals and relative risk calculations. Secondary outcomes were analyzed using appropriate statistical tests based on variable types. Continuous outcomes such as intubation time and hemodynamic parameters were compared using independent samples ttest if normally distributed or Mann-Whitney U test if non-normally distributed. Repeated measures analysis of variance (ANOVA) was used to evaluate hemodynamic changes over time with post-hoc pairwise comparisons. Categorical secondary outcomes including Cormack-Lehane grades and complication rates were analyzed using chi-square test or Fisher's exact test as appropriate. Subgroup analyses were planned to explore potential effect modifications by factors including age groups, BMI categories, specific airway assessment findings, and ASA physical status classification. Multivariable logistic regression analysis was performed to identify independent predictors of first-attempt intubation success while adjusting for potential confounding variables. All statistical tests were two-tailed, and p-values less than 0.05 were considered statistically significant. RESULTS Patient Demographics and Baseline Characteristics A total of 542 patients were initially screened for eligibility during the study period from February 2024 to June 2025. Of these, 28 patients did not meet inclusion criteria, and 14 patients declined participation. The remaining 500 patients who provided informed consent were allocated into the videolaryngoscopy group (n=250) and the direct laryngoscopy group (n=250) using the alternate allocation method. All allocated patients completed the study protocol without withdrawals or loss to follow-up, resulting in complete data availability for analysis. The two study groups demonstrated comparable demographic characteristics. The mean age of patients in the videolaryngoscopy group was 43.7±12.4 years compared to 44.2±11.8 years in the direct laryngoscopy group (p=0.651). Gender distribution was similar between groups, with 58.4% males in the videolaryngoscopy group versus 56.0% males in the direct laryngoscopy group (p=0.598). Mean body mass index was comparable at 26.8±3.7 kg/m² in the videolaryngoscopy group and 27.1±3.9 kg/m² in the direct laryngoscopy group (p=0.382). Distribution of ASA physical status classification showed no significant differences between groups, with ASA I patients comprising 32.8% of the videolaryngoscopy group and 30.4% of the direct laryngoscopy group, ASA II patients representing 52.4% and 54.8% respectively, and ASA III patients accounting for 14.8% and 14.8% in both groups (p=0.778). The types of surgical procedures were similarly distributed, with abdominal surgeries representing the largest category at 38.4% in the videolaryngoscopy group and 40.8% in the direct laryngoscopy group, followed by orthopedic procedures at 28.8% and 26.4%, gynecological surgeries at 18.0% and 19.2%, and other surgical specialties at 14.8% and 13.6% respectively (p=0.824). Preoperative airway assessment parameters demonstrated equivalent baseline difficult airway characteristics between the two groups. Modified Mallampati classification showed Grade III in 64.8% of videolaryngoscopy patients and 62.4% of direct laryngoscopy patients, with Grade IV present in 35.2% and 37.6% respectively (p=0.577). Mean thyromental distance measured 5.8±0.6 cm in the videolaryngoscopy group compared to 5.7±0.7 cm in the direct laryngoscopy group (p=0.228). Mean sternomental distance was 11.6±0.9 cm versus 11.5±0.8 cm (p=0.415), and mean inter-incisor distance was 3.2±0.4 cm in both groups (p=0.889). Restricted neck extension was present in 34.0% of videolaryngoscopy patients and 36.4% of direct laryngoscopy patients (p=0.580), while prominent upper incisors were identified in 28.4% and 30.8% respectively (p=0.554). Table 1: Demographic and Baseline Characteristics Parameter Videolaryngoscopy (n=250) Direct Laryngoscopy (n=250) pvalue Age (years), mean ± SD 43.7 ± 12.4 44.2 ± 11.8 0.651 Male gender, n (%) 146 (58.4%) 140 (56.0%) 0.598 Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 735 BMI (kg/m²), mean ± SD 26.8 ± 3.7 27.1 ± 3.9 0.382 ASA Physical Status, n (%) 0.778 - ASA I 82 (32.8%) 76 (30.4%) - ASA II 131 (52.4%) 137 (54.8%) - ASA III 37 (14.8%) 37 (14.8%) Type of Surgery, n (%) 0.824 - Abdominal 96 (38.4%) 102 (40.8%) - Orthopedic 72 (28.8%) 66 (26.4%) - Gynecological 45 (18.0%) 48 (19.2%) - Others 37 (14.8%) 34 (13.6%) Mallampati Class, n (%) 0.577 - Grade III 162 (64.8%) 156 (62.4%) - Grade IV 88 (35.2%) 94 (37.6%) Thyromental distance (cm), mean ± SD 5.8 ± 0.6 5.7 ± 0.7 0.228 Sternomental distance (cm), mean ± SD 11.6 ± 0.9 11.5 ± 0.8 0.415 Inter-incisor distance (cm), mean ± SD 3.2 ± 0.4 3.2 ± 0.4 0.889 Restricted neck extension, n (%) 85 (34.0%) 91 (36.4%) 0.580 Prominent upper incisors, n (%) 71 (28.4%) 77 (30.8%) 0.554 Primary Outcome: First-Attempt Intubation Success The primary outcome analysis revealed statistically significant superiority of videolaryngoscopy over direct laryngoscopy for first-attempt intubation success in patients with predicted difficult airways. First-attempt success was achieved in 221 patients (88.4%) in the videolaryngoscopy group compared to 182 patients (72.8%) in the direct laryngoscopy group, representing an absolute risk difference of 15.6% (95% CI: 8.7-22.5%, p<0.001). The relative risk of first-attempt success with videolaryngoscopy versus direct laryngoscopy was 1.21 (95% CI: 1.12-1.32), and the number needed to treat to achieve one additional successful first-attempt intubation was 6.4 patients. Among the 29 patients in the videolaryngoscopy group who required more than one attempt, second-attempt success was achieved in 24 patients (82.8%), and third-attempt success in the remaining 5 patients (17.2%), resulting in ultimate success rate of 100% within three attempts. In the direct laryngoscopy group, 68 patients required more than one attempt, with second-attempt success achieved in 54 patients (79.4%), third-attempt success in 11 patients (16.2%), and failed intubation necessitating alternative techniques in 3 patients (4.4%). The overall success rate within three attempts was 100% for videolaryngoscopy and 98.8% for direct laryngoscopy (p=0.248). Table 2: First-Attempt Intubation Success and Number of Attempts Parameter Videolaryngoscopy (n=250) Direct Laryngoscopy (n=250) pvalue First-attempt success, n (%) 221 (88.4%) 182 (72.8%) <0.001 Number of attempts, mean ± SD 1.13 ± 0.37 1.33 ± 0.58 <0.001 Distribution of attempts, n (%) <0.001 - One attempt 221 (88.4%) 182 (72.8%) - Two attempts 24 (9.6%) 54 (21.6%) - Three attempts 5 (2.0%) 11 (4.4%) - Failed intubation 0 (0.0%) 3 (1.2%) Overall success rate (≤3 attempts) 250 (100%) 247 (98.8%) 0.248 Absolute risk difference (95% CI) 15.6% (8.7-22.5%) Relative risk (95% CI) 1.21 (1.12-1.32) Number needed to treat 6.4 Secondary Outcomes: Intubation Time and Glottic Visualization Mean intubation time from laryngoscope insertion to confirmation of correct tube placement was 42.3±12.6 seconds in the videolaryngoscopy group compared to 45.8±15.2 seconds in the direct laryngoscopy group. Although videolaryngoscopy demonstrated a trend toward shorter intubation times, this difference did not reach statistical significance (p=0.065). Median intubation time was 40 seconds (IQR: 34-48) for videolaryngoscopy and 43 seconds (IQR: 36-53) for direct laryngoscopy. When analyzing intubation time stratified by success on first attempt, patients successfully intubated on the first attempt showed mean times of 38.6±9.4 seconds with videolaryngoscopy versus 41.2±11.8 seconds with direct laryngoscopy (p=0.024), indicating significantly faster successful first-attempt intubations with videolaryngoscopy. For patients requiring multiple attempts, cumulative intubation time including all attempts was 76.4±18.2 seconds in the videolaryngoscopy group versus 89.6±24.8 seconds in the direct laryngoscopy group (p=0.012). Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 736 Glottic visualization assessed by Cormack-Lehane grading demonstrated marked superiority of videolaryngoscopy. In the videolaryngoscopy group, Grade I view was obtained in 128 patients (51.2%), Grade II in 82 patients (32.8%), Grade III in 36 patients (14.4%), and Grade IV in 4 patients (1.6%). Conversely, in the direct laryngoscopy group, Grade I view was achieved in only 62 patients (24.8%), Grade II in 92 patients (36.8%), Grade III in 78 patients (31.2%), and Grade IV in 18 patients (7.2%). The distribution of Cormack-Lehane grades differed significantly between groups (p<0.001), with the videolaryngoscopy group achieving Grade I-II views in 84.0% of patients compared to only 61.6% in the direct laryngoscopy group. Table 3: Intubation Time and Glottic Visualization Parameter Videolaryngoscopy (n=250) Direct Laryngoscopy (n=250) pvalue Mean intubation time (seconds), mean ± SD 42.3 ± 12.6 45.8 ± 15.2 0.065 Median intubation time (IQR) 40 (34-48) 43 (36-53) First-attempt intubation time (seconds), mean ± SD 38.6 ± 9.4 41.2 ± 11.8 0.024 Multiple attempts time (seconds), mean ± SD 76.4 ± 18.2 89.6 ± 24.8 0.012 Cormack-Lehane Grade, n (%) <0.001 - Grade I 128 (51.2%) 62 (24.8%) - Grade II 82 (32.8%) 92 (36.8%) - Grade III 36 (14.4%) 78 (31.2%) - Grade IV 4 (1.6%) 18 (7.2%) Grade I-II, n (%) 210 (84.0%) 154 (61.6%) <0.001 Grade III-IV, n (%) 40 (16.0%) 96 (38.4%) Optimization Maneuvers and Intubation Difficulty The requirement for optimization maneuvers differed substantially between groups. External laryngeal manipulation (BURP maneuver) was employed in 42 patients (16.8%) in the videolaryngoscopy group compared to 98 patients (39.2%) in the direct laryngoscopy group (p<0.001). Use of a stylet or bougie was necessary in 38 patients (15.2%) with videolaryngoscopy versus 84 patients (33.6%) with direct laryngoscopy (p<0.001). Change of blade size was required in 8 patients (3.2%) in the videolaryngoscopy group and 24 patients (9.6%) in the direct laryngoscopy group (p=0.004). These findings indicate that videolaryngoscopy facilitated successful intubation with fewer adjunctive maneuvers and equipment modifications. The intubation difficulty scale (IDS) score, which provides a comprehensive assessment of overall intubation difficulty, was significantly lower in the videolaryngoscopy group. Mean IDS score was 2.4±1.8 in the videolaryngoscopy group compared to 4.1±2.3 in the direct laryngoscopy group (p<0.001). An IDS score of zero, indicating minimal difficulty, was achieved in 42.8% of videolaryngoscopy patients versus only 18.4% of direct laryngoscopy patients. An IDS score greater than 5, indicating significant difficulty, was observed in 8.4% of videolaryngoscopy patients compared to 28.4% of direct laryngoscopy patients (p<0.001). Table 4: Optimization Maneuvers and Intubation Difficulty Parameter Videolaryngoscopy (n=250) Direct Laryngoscopy (n=250) pvalue External laryngeal manipulation, n (%) 42 (16.8%) 98 (39.2%) <0.001 Stylet/bougie use, n (%) 38 (15.2%) 84 (33.6%) <0.001 Blade size change, n (%) 8 (3.2%) 24 (9.6%) 0.004 Head position change, n (%) 14 (5.6%) 32 (12.8%) 0.007 Intubation Difficulty Scale score, mean ± SD 2.4 ± 1.8 4.1 ± 2.3 <0.001 IDS Score distribution, n (%) <0.001 - IDS = 0 (minimal difficulty) 107 (42.8%) 46 (18.4%) - IDS 1-5 (moderate difficulty) 122 (48.8%) 133 (53.2%) - IDS >5 (significant difficulty) 21 (8.4%) 71 (28.4%) Hemodynamic Parameters Baseline hemodynamic parameters before induction of anaesthesia were comparable between the two groups. Mean baseline heart rate was 78.4±11.2 beats per minute in the videolaryngoscopy group and 79.1±10.8 beats per minute in the direct laryngoscopy group (p=0.486). Mean baseline systolic blood pressure measured 128.6±14.2 mmHg versus 129.4±13.8 mmHg (p=0.538), mean baseline diastolic blood pressure was 80.2±8.6 mmHg versus 80.8±8.4 mmHg (p=0.431), and mean arterial pressure was 96.3±9.8 mmHg versus 97.0±9.4 mmHg (p=0.455). Dr. Prathap Pancheti, et al. Videolaryngoscopy Versus Direct Laryngoscopy In Predicted Difficult Airways: A Comparative Study. Int. J Med. Pharm. Res., 6 (6): 729‐743, 2025 737 Immediately following intubation (time 0), both groups demonstrated expected increases in heart rate and blood pressure due to sympathetic stimulation associated with laryngoscopy and intubation. However, the magnitude of hemodynamic changes was significantly less pronounced in the videolaryngoscopy group. Mean heart rate immediately post-intubation was 96.8±13.4 beats per minute in the videolaryngoscopy group compared to 104.2±15.6 beats per minute in the direct laryngoscopy group (p<0.001), representing mean increases of 23.5% versus 31.8% from baseline respectively. Systolic blood pressure immediately post-intubation measured 148.2±16.8 mmHg in the videolaryngoscopy group and 156.4±18.2 mmHg in the direct laryngoscopy group (p<0.001), corresponding to mean increases of 15.2% and 20.9% from baseline values. Diastolic blood pressure showed similar patterns at 92.6±10.2 mmHg versus 98.4±11.6 mmHg (p<0.001). Mean arterial pressure increased to 111.1±11.8 mmHg in the videolaryngoscopy group versus 117.7±13.2 mmHg in the direct laryngoscopy group (p<0.001), representing increases of 15.4% and 21.3% respectively. Hemodynamic parameters at 3 minutes post-intubation continued to show significant differences, with the videolaryngoscopy group demonstrating more rapid return toward baseline values. Heart rate at 3 minutes was 88.2±12.6 beats per minute in the videolaryngoscopy group versus 94.6±14.2 beats per minute in the direct laryngoscopy group (p<0.001). Systolic blood pressure was 138.4±15.2 mmHg versus 144.8±16.8 mmHg (p<0.001), and mean arterial pressure was 103.2±10.6 mmHg versus 108.4±11.8 mmHg (p<0.001). By 5 minutes post-intubation, hemodynamic parameters in both groups showed convergence toward baseline. Heart rate measured 83.6±11.8 beats per minute in the videolaryngoscopy group versus 86.2±12.4 beats per minute in the direct laryngoscopy group (p=0.028). At 10 minutes post-intubation, no statistically significant differences were observed between groups, with heart rate at 80.2±11.4 versus 81.6±11.2 beats per minute (p=0.184), systolic blood pressure at 130.4±13.8 versus 132.2±14.2 mmHg (p=0.176), and mean arterial pressure at 97.8±9.6 versus 98.6±9.8 mmHg (p=0.382). Table 5: Hemodynamic Parameters Parameter Videolaryngoscopy (n=250) Direct Laryngoscopy (n=250) pvalue Heart Rate (beats/min), mean ± SD Baseline 78.4 ± 11.2 79.1 ± 10.8 0.486 Immediately post-intubation 96.8 ± 13.4 104.2 ± 15.6 <0.001 3 minutes post-intubation 88.2 ± 12.6 94.6 ± 14.2 <0.001 5 minutes post-intubation 83.6 ± 11.8 86.2 ± 12.4 0.028 10 minutes post-intubation 80.2 ± 11.4 81.6 ± 11.2 0.184 Systolic BP (mmHg), mean ± SD Baseline 128.6 ± 14.2 129.4 ± 13.8 0.538 Immediately post-intubation 148.2 ± 16.8 156.4 ± 18.2 <0.001 3 minutes post-intubation 138.4 ± 15.2 144.8 ± 16.8 <0.001 5 minutes post-intubation 133.2 ± 14.6 136.4 ± 15.2 0.024 10 minutes post-intubation 130.4 ± 13.8 132.2 ± 14.2 0.176 Diastolic BP (mmHg), mean ± SD Baseline 80.2 ± 8.6 80.8 ± 8.4 0.431 Immediately post-intubation 92.6 ± 10.2 98.4 ± 11.6 <0.001 3 minutes post-intubation 86.4 ± 9.4 90.8 ± 10.2 <0.001 5 minutes post-intubation 82.8 ± 8.8 84.6 ± 9.2 0.042 10 minutes post-intubation 81.2 ± 8.4 82.4 ± 8.6 0.142 Mean Arterial Pressure (mmHg), mean ± SD Baseline 96.3 ± 9.8 97.0 ± 9.4 0.455 Immediately post-intubation 111.1 ± 11.8 117.7 ± 13.2 <0.001 3 minutes post-intubation 103.2 ± 10.6 108.4 ± 11.8 <0.001 5 minutes post-intubation 99.6 ± 10.2 101.9 ± 10.8 0.021 10 minutes post-intubation 97.8 ± 9.6 98.6 ± 9.8 0.382 Complications The incidence of intubation-related complications was significantly lower in the videolaryngoscopy group compared to the direct laryngoscopy group. Overall complication rate was 6.4% (16 patients) in the videolaryngoscopy group versus 14.8% (37 patients) in the direct laryngoscopy group (p=0.003), representing a relative risk reduction of 56.8%. Mucosal trauma, evidenced by presence of blood on the laryngoscope blade or endotracheal tube, occurred in 8 patients (3.2%) in the videolaryngoscopy group compared to 22 patients (8.8%) in the direct laryngoscopy group (p=0.008). The severity of mucosal trauma was also less in the videolaryngoscopy group, with minimal bleeding (requiring no