Video Laryngoscopy vs Direct Laryngoscopy or Stylet-guided for Endotracheal Intubation

video laryngoscopy vs direct laryngoscopy Endotracheal intubation can occur in up to 60% of critically ill patients. Though common, the procedure comes with significant risks. If multiple attempts are made to secure the airway, it may contribute to patient morbidity. Using the right laryngoscope can improve the odds of first-attempt success while lowering the incidence of adverse events (AEs).

Join Hospital Procedures Consultants as we review important considerations that can help improve patient outcomes, including the pros and cons of video laryngoscopy and airway management pearls.

Techniques for Endotracheal Intubation

Two techniques are commonly used to perform intubation:

Direct laryngoscopy allows the clinician to get a dynamic assessment of the airway while visualizing the patient’s larynx (voice box) through the mouth. 

Meanwhile, video laryngoscopy improves glottic visualization with the help of a camera and video screen. It effectively reduces the risk of a failed intubation among patients with known or predicted difficult airways.

What Does Current Medical Literature Say About the Success Rates of Video Laryngoscopy and Direct Laryngoscopy?

A multicenter, randomized trial from 7 emergency departments and 10 intensive care units found that successful intubation on the first attempt was more likely in the video laryngoscope group. VL success occurred in 600 of the 705 patients (85.1%) compared to 504 of the 712 (70.8%) in the DL group.

The difference can be attributed to the ability to view the vocal cords. In the VL group, a grade 1 view on the Cormack–Lehane grading scale (where most cords were visible) was reported in 76.3% of the patients compared to only 44.7% of the patients in the DL group. This finding has important clinical implications as failure to intubate the trachea on the first attempt is associated with a 33% higher likelihood of experiencing adverse events.

However, there are still challenges when administering VL. Due to the bulky dimensions of a VL, facilitating accurate endotracheal tube placement may be difficult among patients.

Research also found that the risk of severe complications—such as cardiac arrest, death, new or increased vasopressor use, severe hypotension, and severe hypoxemia—during intubation was similar in the two groups. They affected 21.4% of patients in the video laryngoscope group and 20.9% in the DL group, resulting in a mere 0.5% difference.

Video Laryngoscopy vs Direct Laryngoscopy: Which Is Better for Your Patient?

Failure to intubate the trachea on the first attempt occurs in up to 20% of cases. To top it off, it is associated with severe hypoxemia and cardiac arrest.

Hence, choosing the right technique is important. But how do you choose between them?

A 2017 randomized clinical trial established no difference in the first attempts between video laryngoscopy and direct laryngoscopy (67.7% vs 70.3%). 

More recent research, however, indicates that VL may be superior. Even in the operating room, video laryngoscopy only requires more than 1 intubation attempt among 1.7% of patients compared to 7.6% for DL. VLs are thus being used with increasing frequency.

2 Considerations for Endotracheal Intubation

The goal of tracheal intubation is to achieve first-pass success quickly. Choosing between the two requires a careful analysis of the following factors:

Bougie Vs. Stylet 

A 2018 clinical trial involving patients with difficult airways demonstrated higher first-attempt success rates among the bougie group than patients from the stylet group (96% vs. 82%).

Recent studies, however, show minor, almost negligible differences. A 2021 trial revealed a small 2.6% difference between the bougie group’s 83% first-pass success and the stylet group’s 83%.

On account of its small size, which brings a higher chance of blindly entering the glottic opening, the bougie should be the primary choice for a larger-caliber endotracheal tube during emergency situations. 

Operator Expertise 

A 2023 trial showed that the inability to insert an endotracheal tube or bougie on the first attempt occurred in 49 patients (7.0%) in the VL group and 51 patients (7.2%) in the DL group.

This shows that operator training and experience can influence the likelihood of successful intubation. Such was also the case in a multicenter trial published in 2023.

Among untrained physicians (or those unfamiliar with anatomical landmarks), VL for better laryngeal visualization is easier to learn than DL, which improves first-attempt success rates.

Master Your Video Laryngoscopy and Direct Laryngoscopy Skills 

Video laryngoscopy vs direct laryngoscopy—which is the better option for clinicians and patients? 

Generally speaking, clinicians favor VL as it facilitates prompt diagnosis and treatment while leading to reduced hospital stays by more than one day for five major diagnostic categories.

However, advanced airway equipment like video laryngoscopes are not available in all settings. That’s why clinicians must be familiar with both techniques.

Hospital Procedures Consultants can help you increase your familiarity with these methods. Our basic airway management course will teach you the indications and contraindications for endotracheal intubation. It also discusses complications, risk profiles, and proper positioning. In addition, our simulation-based training helps bridge the knowledge gap, enhances skill competency, and alleviates the anxiety of healthcare workers.

If you want to practice medicine with more confidence and greater skills, visit our website and enroll today.


Prekker, M. E. Driver, B. E. Trent, S. A. Resnick-Ault, D. Seitz, K. P. Russell, D. W. Gaillard, J. P. Latimer, A. J. Ghamande, S. A. Gibbs, K. W. Vonderhaar, D. J. Whitson, M. R. Barnes, C. R. Walco, J. P. Douglas, I. S. Krishnamoorthy, V. Dagan, A. Bastman, J. J. Lloyd, B. D. Gandotra, S. Goranson, J. K. Mitchell, S. H. White, H. D. Palakshappa, J. A. Espinera, A. Page, D. B. Joffe, A. Hansen, S. J. Hughes, C. G. George, T. Herbert, J. T. Shapiro, N. I. Schauer, S. G. Long, B. J. Imhoff, B. Wang, L. Rhoads, J. P. Womack, K. N. Janz, D. R. Self, W. H. Rice, T. W. Ginde, A. A. Casey, J. D. Semler, M. W. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. Randomized Controlled Trial N Engl J Med. 2023 Aug 3;389(5):418-429. doi: 10.1056/NEJMoa2301601. Epub 2023 Jun 16.
Zhang, J. Jiang, W. Urdaneta, F. Economic analysis of the use of video laryngoscopy versus direct laryngoscopy in the surgical setting. J Comp Eff Res. 2021 Jul;10(10):831-844. doi: 10.2217/cer-2021-0068. Epub 2021 Apr 27.
Driver, B. E., MD, corresponding author. Semler, M. W., MD. Self, W. H., MD. Ginde, A. A., MD. Trent, S. A., MD. Gandotra, S., MD. Smith, L. M., MD, PhD. Page, D. B., MD. Vonderhaar, D. J., MD. West, J. R., MD. Joffe, A. M., DO. Mitchell, S. H., MD. Doerschug, K. C., MD. Hughes, C. G., MD. High, K., RN. Landsperger, J. S., PA-C. Jackson, K. E., MD. Howell, M. P., RN. Robison, S. W., MD. Gaillard, J. P., MD. Whitson, M. R., MD. Barnes, C. M., MD. Latimer, A. J., MD. Koppurapu, V. S., MD. Alvis, B. D., MD. Russell, D. W., MD. Gibbs, K. W., MD. Wang, L., MS. Lindsell, C. J., PhD. Janz, D. R., MD. Rice, T. W., MD. Prekker, M. E., MD. Casey, J. D., MD. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation. JAMA. 2021 Dec 28; 326(24): 1–10. Published online 2021

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