When Does a Gold Standard Stop Being Golden?

The Evidence for a New Default

If your goal is safer intubation in critically ill patients, first-pass success has to drive the decision. In the DEVICE trial, first-pass success was 85.1% with video laryngoscopy vs 70.8% with direct laryngoscopy.^[1] That is a 14.3-point absolute difference. In airway management, that is not small.

The usual pushback is “we can predict difficult airways.” We cannot do that reliably enough. In INTUBE, complications occurred at meaningful rates in critically ill intubations across diverse settings, and risk escalated with repeated attempts.^[2] So the practical reality is simple: if prediction is imperfect, your default needs to be robust when attempt one matters most.

Why Attempt One Matters Most

With additional attempts, adverse events increase, including hypoxemia, hemodynamic instability, and esophageal intubation risk.^[2] That is why first-pass success is a patient safety metric, not just a performance stat.

A Better Training Model

Training is another reason this matters. With DL, the trainee sees the view and the attending often does not. Feedback is delayed. With VL, both see the airway in real time. Coaching improves immediately. Adoption data has shown this pattern before: early resistance, then broad support after exposure and routine use.^[4][3]

Direct Laryngoscopy Still Has a Role

The DL-skills objection is legitimate. You still need DL for specific scenarios: heavy contamination, equipment failure, and select anatomy. The right answer is not “abandon DL.” The right answer is “default to VL where evidence supports it, and deliberately preserve DL proficiency.” Even recent guidance flags perceived DL skill loss as a major adoption barrier.^[3]

A Measurement Caveat

There is also a measurement caveat. “First-pass success” is not defined identically everywhere. When definitions include stricter tube-delivery criteria, reported rates can drop by about five points.^[5] That should make us careful with cross-site comparisons, not dismissive of the overall signal.

Bottom Line

Standards should move when evidence moves. Macintosh laryngoscopy was a major advance. It still has a role. But if we are serious about safety in ICU, ED, and resource-constrained environments, we should stop treating legacy default as sacred and start treating first-pass success as the primary endpoint.^[1][2]