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Direct Laryngoscopy Is Here To Stay

Direct Laryngoscopy Is Here To Stay

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Why do more than half of emergency physicians still prefer direct laryngoscopy to the modern video tracheal intubation systems? There are obvious advantages to the look-around-the-curve approach found with video, yet many doctors prefer the simplicity and feel of the direct laryngoscope. It is a debate that has been going on at airway management conferences for over a decade, yet physicians come back again and again to what they know.

Comfort Zone

The answer is complex, but part of it may be comfort level. Doctors and EMS personnel get their training using the direct method – that is their comfort zone. The age of the physician plays a key role in that comfort, too. Younger doctors develop eye and hand coordination as children sitting in front of a video game console. Veteran practitioners did not grow up with a joystick in their hands, however.

For physicians that did their residency in the 1990s, hands-on training involved only a direct laryngoscope. The video system means learning all over again. Even today, residents may do 50 intubations with direct laryngoscopy for every few that require a video view.


With the focus on rising health care expenses and the changes that go with the Affordable Health Care Act, cost is certainly a factor. The initial cost expenditure of the video equipment is considerably more than that of direct laryngoscopy. On top of that, hospitals must worry about maintenance and repair of the LCD monitors and optic tools, stocking specialized blades distinctive to each model and upgrading equipment to stay current. They must train EMS personnel on the care and use of the video hardware, as well. All these additional costs translate into increased expense for patients and hospitals.

The Drawbacks

When researches look past the advantages of an enhanced view, the downside of video becomes evident. Compared side-by-side, the failings of the video system outweighs that of the old-school method. Consider some of the drawbacks of a video laryngoscope.

  • Variable learning curves – not everyone takes to the video view easily
  • Often requires a stylet to pass the tube
  • Intubation takes longer to complete
  • Loss of depth perception
  • More complex delivery
  • Multiple devices require multiple training sessions
  • Visual limitations of LCD in bright lighting

Direct laryngoscopy is more portable and less expensive, although it does come with that 1 percent failure rate that video system manufacturers harp on in their marketing.

The Ongoing Debate

Two key factors often come up in video vs. direct debates. One is the view limitation that occurs with video application due to excess secretions and fogging. This makes using video less effective than the direct method.

The second is the deskilling of emergency medical personnel. Intubation is a skill set that requires continued application. Medics and emergency physicians need to maintain this ability at all times. Constant exposure to a restricted visual field enhances the skill.

Video equipment is reliant on factors that can fail – broken screens, cameras, and power outages, for example. In those situations, the practitioner needs to be able to fall back on direct laryngoscopy. Keeping those skills sharp is essential. Using video equipment lessons their abilities for direct application.

Ultimately, the most persuasive argument is why fix a working mousetrap. While studies show that using a video laryngoscope improves glottic exposure and ascertains correct placement every time, the success rate of direct delivery makes those factors less impressive. Use of a video laryngoscope does improve the view, but how often is that necessary to complete a tracheal intubation safely? For basic intubations, video is an unnecessary step.

Some doctors argue that using video scopes with a hyper-angulated narrow flange device avoids excessive force on the teeth and jaw, but they also fail in situations where there is an excessive fluid or vomit in the airway. A soiled airway obscures the view of the optics enough to require the removal of the device for cleaning or to switch to direct application – the tried and true method.

Most administrations are happy finding a balance between the two methodologies. During a difficult placement, the advantage of a video view makes sense, but for a standard intubation, using direct laryngoscopy is comfortable, cost-effective and practical.

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