Direct versus Video Laryngoscopy


  • the advent of video laryngoscopy has led to some experts stating that it should be considered ‘standard of care’ (a loaded term) or at least best practice
  • this had led to vigorous and sometimes heated debate, especially in the emergency medicine community

“I will unequivocally state that it is wrong for people to practice direct laryngoscopy in 2012.” — Ron Walls on EMRAP September 2012 (he subsequently softened his stance at Essentials 2012, following a firestorm of responses to the EMRAP podcast)



  • tried and tested method
  • portable
  • inexpensive
  • fogging and fluids have less impact on equipment function
  • performance in expert hands approaches or is similar to video laryngoscopy
  • a perfect view is not necessary for successful intubation


  • approx 1% failure rate
  • a very small minority of patients cannot be intubated by this method regardless of of operator skill



  • Eye and airway need not line up
  • Better view when mouth opening or neck mobility is limited (e.g. c-spine precautions)
  • Others can see and help
  • Permits sharing of medical information among the team
  • Generally higher success rate, especially in difficult situations
  • useful for education (e.g. airway anatomy)
  • useful for awake intubation
  • novices who train with video laryngoscopy also learn direct laryngoscopy faster
  • less risk of esophageal intubation
  • less oral trauma (conflicting evidence)
  • less c-spine movement when c-spine precuations in place (conflicting evidence)
  • less haemodynamic response to intubation


  • Variable learning curves
  • may take longer to intubate (conflicting data on this)
  • Passage of tube may be difficult despite great view; stylet often necessary
  • Fogging and secretions may obscure view
  • Loss of depth perception
  • More complicated
  • Potential for equipment failure
  • More expensive
  • Greater processing time and expense
  • may lead to deskilling at direct laryngoscopy over time
  • multiple devices available requiring different skill sets
  • direct laryngoscopy skills are not directly transferable to use of hyperangulated video laryngoscopes
  • many scopes are large in size and difficult to insert in patients with a poor mouth opening (e.g trismus, oropharyngeal abscesses, and tumors)
  • video screen may be difficult to visualise in the brightly lit outdoor setting
  • rapid acceptance may be an example of ‘gizmo idolatry’


  • A device such as the Storz C-Mac Video Laryngoscope (no COI to disclose!) offers the best of both worlds – direct laryngoscopy can be performed in the usual way, with the video as an immediately available back up
  • critical care doctors need to be expert with both techniques

“All departments should have access to video laryngoscopy equipment” — Scott Weingart

References and Links


Journal articles

  • Cheyne DR, Doyle P. Advances in laryngoscopy: rigid indirect laryngoscopy. F1000 Med Rep. 2010 Aug 19;2:61. PMC2990653.
  • Herbstreit F, Fassbender P, Haberl H, Kehren C, Peters J. Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students. Anesth Analg. 2011 Sep;113(3):586-90. PMID: 21680859. [Free fulltext]
  • Hurford WE. The video revolution: a new view of laryngoscopy. Respir Care. 2010 Aug;55(8):1036-45. PMID: 20667151. [Free fulltext]
  • Levitan RM, Heitz JW, Sweeney M, Cooper RM. The complexities of tracheal intubation with direct laryngoscopy and alternative intubation devices. Ann Emerg Med. 2011 Mar;57(3):240-7. PMID: 20674088.
  • Rosenstock CV, Thøgersen B, Afshari A, Christensen AL, Eriksen C, Gätke MR. Awake fiberoptic or awake video laryngoscopic tracheal intubation in patients with anticipated difficult airway management: a randomized clinical trial. Anesthesiology. 2012 Jun;116(6):1210-6. PMID: 22487805.

FOAM and web resources

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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