Does video laryngoscopy beat DL for intubations in the OR?
And how to preserve direct laryngoscopy skills in the video era
Clinicians are increasingly opting for video laryngoscopy over direct laryngoscopy when intubating critically ill patients. At many ICUs in the U.S., intubations by direct laryngoscopy have become a rarity. When they are done, it is usually due to equipment failure or by a clinician seeking to maintain DL skills, not because it is considered more likely to be successful than video.
Major professional societies have not advocated for VL over DL as a first-line method. Nor has there been a definitive trial proving the superiority of video-guided intubation. Rather, this secular trend seems to be driven by the personal preferences of clinicians, informed by their own experience. It’s safe to say that many find the better views offered in VL provide advantages both to the intubator and the intubated.
Randomized trials have had low extrapolability because in critical care settings, the operators have been mostly ED and CCM trainees with limited intubation experience. Because they were trained in the video era, it’s safe to assume that in aggregate, these trainees a) performed a mix of DL and VL intubations; b) performed fewer DL intubations than past generations; and c) had weaker DL skills by comparison.* It was therefore unsurprising that a major trial testing VL vs DL by ED and CCM trainees found VL to be superior:
* One could argue that structured training with a Macintosh-shaped video blade might enhance DL skill acquisition over training with DL alone.
Video laryngoscopy is much easier to learn and perform at lower experience levels compared to DL. The more difficult question to test has been whether VL or DL is superior when performed by experienced operators (i.e., who have performed hundreds or thousands of intubations with both VL and DL).
Except for small single-center trials, no such trial has been performed in the critical care/emergency setting to our knowledge.
The evidence from the operating theater, however, suggests that even among experienced anesthesia professionals, video intubations are more often successful, and therefore possibly safer than direct laryngoscopy.
Germany and Canada
In Germany, among ~500 adults undergoing surgery at four centers who were intubated by experienced attendings, those randomized to McGrath™ (Macintosh-style) VL had a 95% vs. 73% first-pass success rate. Kriege et al, Anaesthesia 2024
Among ~660 adults undergoing elective surgery at four centers in Germany and Canada who were intubated by experienced attendings, first-pass success was 95.7% with McGrath™ Macintosh-style video blades vs 90.3% with DL (statistically significant). Kriege et al Anaesthesia 2023
U.S. (Cleveland Clinic only)
In 7,736 mostly elective surgery patients at the Cleveland Clinic intubated by anesthesia trainees and CRNAs, more than one intubation attempt was required in 1.7% of those randomized to hyperangulated video, vs. 7.6% of those randomized to direct laryngoscopy. Only 0.27% of patients intubated by video had intubation failure compared to 4% with DL.
More than half the patients were intubated by anesthesia residents, fellows, or CRNAs in training. Less than 3% were intubated by attendings. Notably, anesthesia residents typically perform hundreds of intubations in their first year of training. Ruetzler et al, JAMA 2024
Caveats and Cautions
At least one study (MACMAN) found that video laryngoscopy led to longer intubation times and more complications. It’s possible that the beautiful views of the glottis provided by video laryngoscopy might lull operators into complacency, dangerously extending apneic time during intubation. In MACMAN, trainees performed >80% of the intubations; this issue likely becomes less problematic with experience.
The lower success rates with DL seen in the operating rooms in these studies may also be a sign of deteriorating DL skills in the video era, or of operators’ strong personal preferences for video over DL.
At the Cleveland Clinic, for example, the design permitted an operator to (hypothetically) abandon DL after a half-hearted attempt and switch to VL. This would be counted as an “intubation failure” for DL.
By contrast, among 514 patients intubated by experienced helicopter-based first responders, reported intubation success was 98.1% for those randomized to the McGrath™ vs. 98.5% for direct laryngoscopy. Over 75% of patients intubated with DL required only one or two attempts. These figures are far higher than any reported elsewhere, even in uncomplicated elective surgeries in healthy patients. This trial should probably be disregarded, because these clinicians had near-superhuman skills we can’t hope to replicate (unless there was another explanation for the exceptional success rate).
Guidelines Lean Toward Video
Major societies haven’t advocated for video as first-line for intubation in all patients. Such a recommendation would have significant economic and liability implications for operating theaters throughout the U.S. (most of which do not use video as a standard) and abroad.
The American Society of Anesthesiology endorses VL for predicted difficult airways (“video-assisted laryngoscopy in patients with predicted difficult airways improves laryngeal views and first-attempt intubation success compared to direct laryngoscopy”), as does the Difficult Airway Society.
The Canadian Airway Focus Group endorses a video-first approach: “On balance, and resources allowing, the CAFG recommends the routine primary use of VL with an appropriate blade type for all tracheal intubations.”
The Society for Obesity and Bariatric Anesthesia advises, “A videolaryngoscope should be used as the first-line technique” in obese patients.
Can Both VL and DL Be Taught Well?
Postgraduate educators have had variable responses to the rise of video laryngoscopy. Some have embraced it to the point of virtually abandoning training direct techniques at all. With a finite number of teaching cases, those who aim to produce intensivists skilled in both techniques face significant challenges.
One editorialist warned,
In the past 6 months, we have treated three patients needing immediate airway management, in whom videolaryngoscopy had failed, but all patients had successful tracheal intubation using a Macintosh-shaped blade.
Another responded,
In our hospital, we have used videolaryngoscopy for all tracheal intubations since 2017, with approximately 5000 tracheal intubations per year, and have had no reported cases where this occurred. … There are multiple case series where videolaryngoscopy has rescued direct laryngoscopy at a rate of > 90% success, but none we are aware of where the converse is true.
Educators can use Macintosh-style video blades (from any vendor) to teach direct laryngoscopy, with video available as an adjunct or in the event of difficulty.
It’s probably inevitable that direct laryngoscopy skills will decline in the video era, but they don’t need to disappear.
What has been your experience with direct and video intubation? What’s the culture and practice at your institution and community? How should the next generation best be trained? Please comment below and share as many details (nationality, training level, etc) as you can.
From seven years in the ED then 25 years in anesthesia, I have used every technique available to access airways.
The Shikani fiber optic is probably the best tool for oral f/o.
It is taught wrong.
Stand to the side of the patient.
Access and traction tongue.
Place loaded scope into the mouth.
Immediately look and follow the base of tongue to epiglottis.
Assistant w jaw lift.
Intubate.
As fast or faster than DL.
Given the physics of the scope, it is difficult at best to stand at the head of the patient and defeats the early look and smooth progression to the cords.
Fast load
Portability
Ease of use
No broken teeth
Are pluses
Nasal still requires traditional f/o.
All the drawbacks of f/o still apply mostly relating to obstruction of view.
Blood, mucous, gastric contents all still major obstacles that may favor DL.
Great article. I work at a Level 1 trauma center and we have multiple VL’s for the OR. The anesthesia providers still tend to use traditional DL for most airways unless it’s a difficult airway exam. Things like equipment turnover, missing blades or stylets, etc., tend to make accessing a blade harder than it should be. Equipment also tends to break more times than one would think. I’ve been in anesthesia for 15 years and I’ve seen the trajectory with VL increasing; especially in ICU. Personally most of my intubations are done with a traditional laryngoscope and I am comfortable using all airway platforms- direct, video, and FOB ( which is slowly being replaced by VL)