Video Laryngoscopy or Direct Laryngoscopy for Trainees

According to a 2012 meta-analysis difficult and failed intubations in the operating room occur 1.8 – 5.8% and 0.13 – 0.30% of the time respectively. Emergent intubation, outside of this environment (i.e emergency department, ICU, and medical ward) is typically associated with a much higher risk of difficulty and complications due to many patients rapidly deteriorating. Recently, I had a discussion on twitter with Jeffrey Hill (@_drjeffy) and Taylor Zhou (@canibagthat) about what is the best way to teach trainees to intubate: Video Laryngoscopy (VL) or Direct Laryngoscopy (DL) for Trainees?

How common is difficult airway and complications of intubation outside the OR?


In the ICU (136 Intubations) [1]

  • 13.2% of all intubations required ≥3 attempts
  • 6.6% of expert/faculty intubations required ≥3 attempts
  • 10.3% of all intubations required > 10 minutes
  • Overall risk of complications in 39% of intubations
    • Severe Hypoxemia (19.1%)
    • Severe Hypotension (9.6%)
    • Esophageal Intubation (7.4%)
  • Overall ICU and hospital mortality 15.4% and 29.4% respectively (p = 0.46 and 0.25 respectively)

Conclusion:  Over 1/3 of intubations done in the ICU had complications associated with them in this study


On the Wards (150 Intubations) [2]

  • 76% 1st pass intubation rate overall
  • Complication rates: 27% emergent intubation vs 22% elective intubation
  • Biggest complications:
    • >2 attempts in 9%
    • Esophageal Intubation in 9%
  • No survival difference between emergent intubation (59%) vs elective intubation (50%) [p = 0.46]
  • No survival difference between patients with complications (48%) vs no complications (54%) [p = 0.63]

Conclusion: Emergent intubation on the inpatient wards had a nearly 1/3 complication rate in this study


In the Emergency Department (280 Intubations) [3]

  • 83% 1st pass intubation rate overall
  • 1st pass intubation rate 81% for VL vs 83% for DL (p = 0.59)
  • Intubation failure rate 14% for VL vs 8% for DL (p = 0.12)
  • Median time to successful intubation 42 seconds for VL vs 30 seconds for DL (p <0.01)

Video Laryngoscopy

Does video laryngoscopy increase success rate of emergent tracheal intubation vs direct laryngoscopy in untrained medical personnel? [4]

  • Overall success rate GlideScope technique (93%) vs Direct laryngoscopy technique (51%) [P < 0.01]
  • Time for intubation: 89 +/- 35 s for direct laryngoscopy vs 63 +/- 30 s for GlideScope technique (P < 0.01)

Conclusion:  In untrained medical personal, VL had higher success rate of intubation and quicker time to intubation vs DL

How important is successful 1st pass intubation in care of patients? [5]

  • First attempt success = 14.2% complication rate
  • Two attempts = 47.2% complication rate
  • Three attempts = 63.6% complication rate
  • Four or more attempts = 70.6% complication rate
  • Most common complication was oxygen desaturation

Clinical Take Home Point: As the number of attempts at intubation increases, so does the incidence of complications


Thoughts on Twitter

Video Laryngoscopy or Direct Laryngoscopy

Video Laryngoscopy or Direct Laryngoscopy


Results from Voting

How Should Trainees Be Trained to Intubate?

VL vs DL for Training

Should Video Laryngoscopy Be the 1st Attempt Best Practice For Intubation?

VL as 1st Attempt

Results from Voting:  Its a draw!!!  What this tells us is that it doesn’t matter what your plan A is for intubation, but you should also be good at a plan B and plan C so that you can work in any environment!!!

Screen Shot 2015-02-27 at 4.49.35 PMReferences:

  1. Griesdale DE et al. Complications of Endotracheal Intubation in the Critically Ill. Intensive Care Med 2008. PMID: 18604519
  2. Benedetto WJ et al. Urgent Tracheal Intubation in General Hospital Units: An Observational Study. J Clin Anesth 2007. PMID: 17321922
  3. Platts-Mills TF et al. A Comparison of GlideScope video Laryngoscopy versus direct Laryngoscopy Intubation in the Emergency Department. Acad Emerg Med 2009. PMID: 19664096
  4. Nouruzi-Sedeh P et al. Laryngoscopy via Macintosh Blade Versus GlideScope: Success Rate and Time for Endotracheal Intubation in Untrained Medical Personnel. Anesthesiology 2009. PMID: 19104167
  5. Sakles JC et al. The Importance of first Pass Success When Performing Orotracheal Intubation in the Emergency Department. Acad Emerg Med 2013. PMID: 23574475

For Other Peoples Opinions Check Out:

Cite this article as: Salim Rezaie, "Video Laryngoscopy or Direct Laryngoscopy for Trainees", REBEL EM blog, March 5, 2015. Available at:
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM

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4 thoughts on “Video Laryngoscopy or Direct Laryngoscopy for Trainees”

  1. I think that we would all agree that VL is better/more successful than DL. I have heard the term that DL is dead. I teach residents and this is certainly not my practice nor the way I teach. There are a ton of ER’s out there without VL(I have worked at several). Also what if the VL breaks, dies, can’t find the stylet etc. If we are to prepare our residents to be successful in whatever arena they are going to work in we are doing them a disservice by neglecting DL. I think that the best way to to teach them simultaneously.

  2. I believe that not teaching DL is very irresponsable! It all depends on where are you doing your clinical work. In Chile, prob 95%? of the EDs, do not have any kind of video laringoscopy, so no matter how great you technique is, once they are out of residency, they are on their own… well they have their patient that needs to be intubated and a laryngoscope.

    • Hello Nico,
      I 100% agree that residents should be trained on all modalities for intubation, but the question is should they be trained on VL first, DL first, or both concurrently. So in other words I agree with you that they should be trained on both, but is there a particular order we should be doing it for both the resident and for patient centered outcomes. Hope this clarifies.


  3. Hi Salim,

    Thank you for all of this information. The post is very nicely put together and certainly taught me some info.

    My only critique is that I don’t see modern laryngoscopy as being dichotomous (i.e. DL vs VL). It used to be when the video options were all hyper-angulated in nature (i.e. the original glidescope device); however, that isn’t the case any longer. I see modern laryngoscopy as being comprised of three VERY distinct techniques, specifically: DL, Standard Geometry VL and Hyper-angulated VL. All with VERY different pros and cons.

    My favorite way of teaching DL is with a standard geometry video laryngoscope while the trainee is “doing DL” and I am looking at the screen. It certainly gives you more situational awareness, while also empowering you to give much more effective feedback.

    Thanks for the opportunity to comment…



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