Jun 28, 2024

The Paradigm Shift in Airway Management: Is Direct Laryngoscopy Dead?

By: Andrew Napier, MD

The history of airway management in both emergency medicine and anesthesiology is deeply rooted in direct laryngoscopy (DL). However, in recent years, the widespread adoption of video laryngoscopy (VL) has stirred a paradigm shift. The question many are asking now is: Is direct laryngoscopy effectively obsolete?

The rising prominence of VL over DL has been fueled by numerous studies pointing to its superiority, especially in challenging intubation scenarios. A comprehensive Cochrane Review updated in 2022 analyzed 222 studies with 26,149 participants undergoing tracheal intubation. The review found moderate-certainty evidence that all designs of VL likely reduce rates of failed intubation, result in higher rates of successful intubation on the first attempt, and provide improved glottic views compared to DL. The authors went so far as to say “… video laryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.” (Hansel et al., 2022).

In the realm of emergency medicine, a study published in the Annals of Emergency Medicine in 2021, analyzing 4,449 emergency department (ED) intubations for trauma patients from the National Emergency Airway Registry, showed that first-pass success was significantly higher with VL as compared to DL (90% versus 79%). The study also concluded that VL was associated with twice the odds of first-pass success when compared to DL (Trent et al., 2021).

The COVID-19 pandemic further accentuated the shift towards VL. The risk of aerosol transmission with DL led to VL becoming the preferred method due to the increased distance it offered between the healthcare provider and the patient's airway (Cook et al., 2020).

The transition towards VL is also becoming more evident in medical education. Trainees are now being taught VL as the primary technique, capitalizing on the advantage of simultaneous airway visualization by both the teacher and trainee. This allows for real-time feedback, promoting more efficient skill acquisition.

Given the importance of repetition in mastering airway management techniques, the real-time feedback offered by VL contributes to fewer errors and greater success rates. It’s vital that we embrace this shift as we prepare the next generation of healthcare providers.

So, has DL met its demise? It’s likely too soon to conclusively say so. DL remains a critical skill in certain situations and for providers trained predominantly in its use. Nevertheless, the trend is undeniable: VL is emerging as the new standard in airway management, offering an effective blend of safety, efficacy, and learning advantages.

  1. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Video laryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database of Systematic Reviews 2022, Issue 4. Art. No.: CD011136. DOI: 10.1002/14651858.CD011136.pub3. 

  2. Trent SA, Kaji AH, Carlson JN, McCormick T, Haukoos JS, Brown CA 3rd; National Emergency Airway Registry Investigators. Video Laryngoscopy Is Associated With First-Pass Success in Emergency Department Intubations for Trauma Patients: A Propensity Score Matched Analysis of the National Emergency Airway Registry. Ann Emerg Med. 2021. DOI: 10.1016/j.annemergmed.2021.07.115.

  3. Cook TM, El‐Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID‐19. Anesthesia. 2020 Jun;75(6):785-799. doi: 10.1111/anae.15054.