Video Laryngoscopy vs. Augmented Direct Laryngoscopy in the ED

Daniel M. Lindberg, MD


Video wins again.


Video laryngoscopy (VL) has been shown to make intubation easier and safer compared with traditional direct laryngoscopy (DL). These authors assessed intubation success for VL compared with several inexpensive and widely taught methods to augment DL (laryngeal manipulation, ramped positioning, bougie, and combinations of these). Data were obtained from the National Emergency Airway Registry (NEAR), a prospective observational registry of emergency department (ED) intubations in 25 academic and community hospitals.


During 2016 and 2017, NEAR included 11,714 intubations, of which 3002 used unaided VL and 3936 used augmented DL as the first approach. First-pass success was significantly higher for VL (91%) than for any augmented DL approach (69%–82%), even though the VL group had a higher proportion of patients with predictors of difficult airway. Results were stable after adjusting for predictors of intubation difficulty and in subgroup analyses of VL intubations with hyperangulated or standard-geometry blades, specific augmentation techniques, and intubator training. Adverse events were similar in the VL and DL groups.


VL is more expensive than these augmenting procedures, but given the consequences of a failed intubation, it is worth the cost. In the year 2020, I hope that most emergency clinicians have good access to, and experience with, VL. Be prepared to defend your decision if you choose DL and something goes wrong.


Brown CA 3rd et al. Video laryngoscopy compared to augmented direct laryngoscopy in adult emergency department tracheal intubations: A National Emergency Airway Registry (NEAR) study. Acad Emerg Med 2020 Jan 20; [e-pub].



Copyright © 2020. Massachusetts Medical Society. All rights reserved.