Lit Matters 2: Once Again, VL Outperforms DL

Video laryngoscopy improves first-pass endotracheal intubation success in critically ill adults in the ED and ICU. In a large randomized trial, VL beat direct laryngoscopy by a clinically meaningful margin without reducing severe peri-intubation complications.

Video Versus Direct Laryngoscopy

• First-pass success advantage: VL achieved first-pass tracheal intubation in 85% of critically ill adults versus 70.8% with DL, a result strong enough that the trial was stopped early.
• Glottic view superiority: Inadequate laryngeal view was far less common with VL, occurring on 3.7% of first attempts versus 17.3% with DL, which helps explain the success gap.
• Complication rate reality: Severe complications were essentially unchanged despite better first-pass success, with major peri-intubation events around 21% in both groups.
• Operator experience effect: The benefit of VL narrowed as intubators became more experienced, with the edge shrinking to about 5% after more than 100 prior tubes. We get into what that means for seasoned DL users in the episode.
• Practical airway takeaway: Most study intubations were done by residents or fellows with modest prior experience, making VL the more reliable default for the clinicians who perform emergency airways less often now.