The video laryngoscope vs. direct laryngoscope question has moved from opinion to evidence. Over the last five years, several large randomized trials have compared the two devices in operating rooms, emergency departments, and intensive care units. This guide summarizes what those trials found, where the results are strong, where they are weaker, and when direct laryngoscopy still has a place on the airway cart.
What separates the two devices
A direct laryngoscope requires the operator to create a straight line of sight from the mouth to the glottis. To achieve that, the clinician lifts the tongue and jaw with a Macintosh or Miller blade. The view depends on head position, mouth opening, and the force applied.
A video laryngoscope places a camera near the tip of the blade. As a result, the operator sees the glottis on a screen instead of looking directly down the airway. In other words, the clinician no longer needs to align the oral, pharyngeal, and laryngeal axes.
Video blades come in two main shapes:
- Standard geometry (Macintosh style) blades, which allow both a screen view and a direct view.
- Hyperangulated blades, which curve sharply and work almost entirely through the screen.
The shape matters because it changes technique, tube delivery, and the need for a stylet. For a deeper look at that choice, see our guide to hyperangulated vs Macintosh blades for difficult airways.
Video laryngoscope vs direct laryngoscope in critically ill adults
The most cited trial is DEVICE, published in the New England Journal of Medicine in 2023. It enrolled 1,417 critically ill adults across 17 emergency departments and ICUs in the United States.
First-attempt success was 85.1% with video laryngoscopy and 70.8% with direct laryngoscopy. Because the difference was so clear, the trial stopped early for efficacy. However, severe complications were similar between groups, at 21.4% and 20.9%.
One detail is often missed. Most operators in DEVICE were early in training, and 97% had performed fewer than 250 intubations. Therefore, the trial tells us a lot about real teams in teaching hospitals, where residents and fellows do much of the work.
Emergency department registry data point to the same. A National Emergency Airway Registry analysis of 11,714 intubations found that unaided video laryngoscopy outperformed direct laryngoscopy, even when DL was supported by a bougie, external laryngeal manipulation, or ramped positioning. Video laryngoscopy was also linked to fewer esophageal intubations.
Video laryngoscope vs direct laryngoscope in the operating room
Elective surgical patients are a different population. They are usually fasted, stable and well preoxygenated. For that reason, many anesthesiologists assumed direct laryngoscopy would perform just as well in theatre.
A large crossover trial in JAMA in 2024 tested that assumption. Researchers analyzed 8,429 procedures in adults having surgery that required a single lumen tube. With video laryngoscopy, the need for more than one attempt fell from 7.6% to 1.7%.
Moreover, the advantage held across the surgical population, not only in patients predicted to be difficult. This finding supports the move toward video laryngoscopy as a default device, rather than a rescue tool kept for emergencies.
What systematic reviews add
Single trials can mislead, so pooled analyses matter. The Cochrane review updated in 2022 concluded that video laryngoscopes probably reduce failed intubation and improve glottic views compared with direct laryngoscopy. In addition, the authors found less hypoxemia and fewer airway injuries with video devices.
A 2024 systematic review in emergency settings reported higher first attempt success with video laryngoscopy, with a risk ratio of 1.09. It also found fewer complications. Still, overall success after multiple attempts did not differ. That nuance matters: video laryngoscopy helps most on the first try, which is when patients are least likely to desaturate.
How guidelines now position each device
Professional societies have followed the data. The Difficult Airway Society 2025 guidelines recommend that video laryngoscopy be available for every tracheal intubation and used as a first-line option. We cover this in detail in our summary of the DAS 2025 guidelines on video laryngoscopy.
Similarly, the American Society of Anesthesiologists 2022 practice guidelines list video laryngoscopy as a primary approach in predicted difficult airways. For US teams, our breakdown of the ASA guidelines for video laryngoscopy explains what that means in daily practice.
Video laryngoscope vs direct laryngoscope by clinical setting
The size of the benefit varies with the setting and the operator. Here is how the evidence reads for each environment.
Emergency department. Patients are often unfasted, hypoxemic or unstable. In this setting, first attempt success carries the most weight. Both DEVICE and registry data support video laryngoscopy as the default device, and our guide to the best video laryngoscope for the emergency department covers selection in detail.
Intensive care unit. ICU intubations combine physiological instability with limited reserve. Because desaturation happens fast, avoiding a second attempt is a priority. DEVICE included ICU patients, so its findings apply directly.
Operating room. The 2024 JAMA data show a smaller absolute gain, but it holds across a large volume of cases. Even so, a few extra percentage points matter when a hospital performs thousands of intubations a year.
Pediatrics and neonates. Evidence is growing, especially for trainees. Smaller Miller and Macintosh video blades let teams keep their usual technique while sharing a screen view. See our review of video laryngoscopy for pediatric and neonatal intubation.
Teaching hospitals. A shared screen lets supervisors see exactly what the trainee sees. As a result, coaching becomes specific rather than guesswork, which is one reason training programs adopted video devices early.
When direct laryngoscopy still has a role
The video laryngoscope vs direct laryngoscope debate does not mean DL should vanish. There are real situations where a direct blade remains useful:
- Blood, vomit, or secretions can obscure a camera lens, while a direct view may still work with strong suction.
- Device failure or a flat battery requires a backup that needs no power.
- Skill maintenance matters, because some guidelines still expect clinicians to perform direct laryngoscopy competently.
- Standard geometry video blades let operators use direct and video views together, which keeps DL skills current.
In practice, the strongest position is not one device over the other. Instead, teams should have a video laryngoscope at every intubation, with standard geometry blades that preserve direct skills and hyperangulated blades for the hardest airways.
Cost and procurement considerations
Price is often the reason departments still default to direct laryngoscopes. A metal Macintosh handle and blade costs very little, while a video system adds a monitor, blades and maintenance.
However, total cost looks different once failed attempts enter the picture. Repeated attempts are linked to hypoxemia, prolonged procedures and unplanned ICU stays. As a result, many hospitals now compare cost per successful intubation rather than device price alone.
Procurement teams should also weigh:
- reusable versus single use blade costs per case,
- reprocessing time, staff and validated sterilization methods,
- monitor durability, battery life and charging time,
- training needs and video recording for teaching.
Our video laryngoscope buying guide for US hospitals walks through each of these factors in more depth.
How Astra-vue supports both techniques
Astra-vue designs its system so teams can use video and direct techniques on one platform. The Mini Monitor has a 4 inch touchscreen, a 720p HD camera, video recording, 16GB of storage and about 85 minutes of battery life. It also offers mini HDMI output for teaching screens.
Reusable Ultra Blades are available in Macintosh sizes 1 to 4, Miller sizes 000 to 1, and hyperangulated and channeled hyperangulated designs. For single-use workflows, the Pro Blade and the anti fog Lite Blade offer disposable options. The system is FDA registered and listed, CE marked under MDR and built under ISO 13485. You can review every option on our products page or contact our team for a demonstration.
Video laryngoscope vs direct laryngoscope: FAQs
Is a video laryngoscope better than a direct laryngoscope?
For first-attempt success, the current evidence favors video laryngoscopy in most adult settings. DEVICE and the 2024 JAMA trial both showed fewer failed first attempts. However, severe complication rates were similar in DEVICE, so the benefit is mainly fewer repeated attempts.
Should hospitals replace every direct laryngoscope with a video laryngoscope?
No. Direct laryngoscopes remain a sensible backup for device failure and heavy soiling. Most guidelines also expect clinicians to keep basic DL skills.
Does a video laryngoscope reduce complications?
Pooled analyses suggest less hypoxemia and fewer airway injuries. Even so, large trials have not shown a consistent drop in severe complications, so teams should not oversell this point.
Which blade should a department buy first?
Most adult departments start with standard geometry Macintosh 3 and 4 video blades, then add hyperangulated blades for predicted difficult airways. Pediatric units also need smaller Miller and Macintosh sizes.
What is the main limitation of video laryngoscopy?
The camera can be obscured by blood or secretions. Also, with hyperangulated blades, seeing the glottis does not always mean the tube passes easily, so a shaped stylet is usually required.
