Airway, Critical Care, Critical Care Alert

Critical Care Alert! Video Laryngoscopy vs. Direct Laryngoscopy During Urgent Endotracheal Intubation

A 42-year-old man who is diagnosed with community acquired pneumonia is transferred from the medical floor to the ICU for increased O2 requirements. After placing him on BiPAP, he remains tachypneic and continues to have increased work of breathing. At this point you decide to intubate the patient for hypoxic respiratory failure. Your junior ICU resident is preparing to intubate using direct laryngoscopy. What advice should you give this resident to avoid dire consequences with this high-risk procedure?


Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Crit Care Med. 2015;43(3):636-641.


Comparing the difference between GlideScope video laryngoscopy (GVL) and direct laryngoscopy (DL) in achieving first pass success for the critically ill airway.


Historically, direct laryngoscopy has been the most common device for intubation. In the critically ill population undergoing urgent endotracheal intubation (UEI), first-attempt success rates are lower because of the urgency, uncontrolled setting, comorbidities, and varying expertise of available practitioners. Modern airway management focuses on securing the critically ill airway on the first attempt with minimal complication rates. This paper hypothesized that GVL would be superior to DL in first-attempt success among non-anesthesiologists.


  • Single center, prospective, randomized controlled trial of urgent endotracheal intubation performed by pulmonary and critical care medicine fellows.
  • The primary recommended induction agent for intubation was Propofol, at a dose of 1 mg/kg. Etomidate could be used at the operator's discretion in cases of preinduction hypotension. Neuromuscular blocking agents were not routinely used per department protocol.

Inclusion Criteria: All patients who require urgent and emergent intubation.

Exclusion Criteria:

  1. Elective intubation
  2. History of difficult intubation
  3. Limited mouth opening, oropharyngeal masses, or swollen tongue
  4. Oxygen saturation less than 92% after bag valve mask ventilation

All odd-numbered intubations were done using DL as a first-attempt device (ie, the first patient intubated by each fellow was attempted using DL as the initial device).

All even-numbered intubations were done using GVL as the initial device (ie, the second patient intubated by each fellow was attempted using GVL as the initial device).

Primary Outcome: Rate of first-attempt success

Secondary Outcome: O2 sats <80%, SBP <70mmHg, esophageal intubation, emesis observed during intubation, dental injury, and cardiac arrest

Key Results

In this study, 117 patients met inclusion criteria; 57 were randomized to the GVL group, and 60 to the DL group.

First-attempt success rates:

  • GVL: 74%
  • DL: 40%

Required attempts >2:

  • GVL: 9%
  • DL: 27%

Time to intubation:

  • GVL: 120 seconds
  • DL: 218 seconds

All patients in the GVL group were intubated successfully with a GVL.

All patients in the DL group who could not be intubated with a DL were intubated with a GVL.

There was no significant difference in rates of complications between DL and GVL. However, there were more non-statistically significant complications with DL.


GVL showed improved glottic views and first-attempt success compared with DL in nonparalyzed patients.