Comparative Hemodynamic Stability and Physiologic Stress During Difficult Airway Intubation: Video Laryngoscopy Versus Direct Macintosh Laryngoscopy

Abstract

Background: Direct laryngoscopy can provoke marked sympathetic stimulation, and this effect may be amplified in difficult airway scenarios where laryngoscopic force and procedural complexity increase. Evidence suggests videolaryngoscopy may attenuate physiologic stress responses during intubation, but comparative data in difficult airways remain clinically important. Objective: To compare hemodynamic variability and physiologic responses during intubation using Macintosh laryngoscopy versus video laryngoscopy in patients with difficult airway predictors. Methods: A comparative clinical study was conducted among adults with difficult airway features. Participants underwent intubation using Macintosh or a video laryngoscope, and peri-intubation heart rate, blood pressure, mean arterial pressure, oxygen saturation, ETCO₂ categories, and ECG findings were recorded and compared between devices. Results: Sixty-eight participants were analyzed. Videolaryngoscopy demonstrated more stable peri-intubation physiology with significant between-device differences favoring video laryngoscopy for heart rate (mean difference 0.48; 95% CI 0.22–0.74; p<0.001), blood pressure (1.18; 0.58–1.78; p<0.001), mean arterial pressure (2.12; 1.50–2.74; p<0.001), and SpO₂ (0.74; 0.43–1.05; p<0.001). Extreme responses and ECG abnormalities were observed predominantly with Macintosh laryngoscopy. Conclusion: In difficult airway conditions, videolaryngoscopy is associated with reduced hemodynamic variability and fewer extreme physiologic responses compared with Macintosh laryngoscopy.