Is Direct Laryngoscopy Antiquated and Irrelevant Today?

Although dental school was replete with intense memories (Stab Lab, anyone?), I would wager that most who completed postgraduate education with training in anesthesia likely remember the profound rush of successfully inducing, mask ventilating, and intubating a patient for the first time. Picking up the laryngoscope only to be told to hold it correctly in the opposite hand, sliding its blade along the lateral tongue, and gently lifting upward, we looked with wide eyes down into the patient’s mouth as our attending asked, “Do you see it?” We proceeded onward with little to no idea what they meant, and having been told by our all-knowing upper-level coresidents to “fake it until you make it,” we advanced the endotracheal tube (ETT) into place with fewer parts skill and more parts hope and wonder.

For any anesthesia novice, these basic airway management skills are usually quite foreign at first but quickly become routine with time and experience. Direct laryngoscopy (DL) using either a Macintosh or Miller blade has long been a standard clinical skill learned during formal training for deep sedation and general anesthesia providers for dentistry. An integral part of most intubation techniques, DL not only provides critical access and views needed to successfully insert an ETT but also helps with the appreciation of key aspects and anatomic relationships pertinent to the airway.

In the mid-1700s, physicians used mirrors and reflective surfaces to indirectly view the vocal cords and upper airway anatomy (ie, indirect laryngoscopy). This method persisted until 1895 when Alfred Kirstein performed the first DL with his autoscope, a modified esophagoscope, and paved the way for the advent of a laryngoscope with a distal light source to further improve intubating conditions. Subsequent blade modifications by Robert Miller (1941) and Robert Macintosh (1943) created the popular and ubiquitous designs we know today.¹ DL was the quintessential skill tied to endotracheal intubation for decades. But in the late 1960s, the advent of flexible fiber-optic bronchoscopes led to indirect laryngoscopy’s return. These small, flexible scopes were primarily reserved for known and emergent difficult-airway patients and typically for care provided exclusively in the traditional hospital setting due to their cost. Fending off other challenges, such as the invention of the laryngeal mask airway by Archie Brain in 1981, DL has successfully maintained its position as a critical airway management skill necessary for all anesthesia providers.

However, with the advent of portable and relatively affordable video systems in the early 2000s, indirect video laryngoscopy (VL) quickly began staking its claim as the preeminent, preferred laryngoscopy technique. GlideScope (Verathon, Inc) was released in 2001 as the first commercially available VL system. It featured a video cable that tethered the handle/blade to a small monitor for viewing. The blade was hyperangulated and contained a small camera port located in the distal third of the blade that produced live, high-resolution images of the airway. Over time, other commercially available VL systems were introduced that built upon the successes of the GlideScope. These advances included additional blade sizes and shapes, a channel to guide the ETT, and merging the handle/blade with the monitor to produce units that could be easily held and viewed with one hand. As of 2025, there are at least 6 well-known, different VL systems for sale in the US.

Growth in the use of VL systems has been exponential since its release. VL is especially preferred when faced with a difficult airway, as it is often capable of delivering superior views that help increase rates of successful intubation, even in obvious situations where DL would likely fail. Looking at the literature, multiple systematic reviews and meta-analyses have compared VL with DL, some focusing exclusively on adults and others on pediatric patients, and concluded that VL improves intubation (ie, increased success rates for first-pass intubation, visualization of the glottis, decreased number of intubation attempts) compared with DL.^2–6 One study even looked at VL vs DL for nasotracheal intubation, a common approach in dental/oral and maxillofacial surgery cases, and found that VL use led to shorter intubation times, higher first-attempt success rates, and less need for additional maneuvers.⁷

Given these stated advantages of VL over DL, should every anesthesia provider routinely use VL instead of DL? Should VL be reserved only for emergencies or difficult airway situations? Some may wonder if DL is even a skill worth learning these days.

Providing data-driven answers to these questions is somewhat difficult. Much of the existing literature suggests clear benefits with VL, so the case for routine VL use over DL could be made. However, although one study systematically assessed the literature for VL vs DL use for novices and concluded that VL use led to improved intubation success rates, glottic visualization, and intubation times,⁸ several other studies found conflicting results. Even if VL is used routinely, providers should still maintain DL proficiency to help prevent skill atrophy in case an accident or failure occurs, for example if the VL scope is dropped and breaks.

Despite having clear advantages when it comes to difficult airway situations, VL requires its own unique approach that differs from DL. Most VL systems have a camera or optical port fixed within the blade, so lifting upward (as is common with DL) will embed the blade/camera into the soft tissues and impair visualization. Furthermore, although many VL systems can improve airway views, actual advancement of the ETT through the glottic opening may be less straightforward, requiring a stylet and extensive or exaggerated bends and leading to difficulties for unexperienced providers. If VL is intended to be used as part of rescue efforts for an unanticipated difficult airway, users must already know how to use the VL device, otherwise such efforts may be in vain. In short, the time to practice using a VL device is not during an emergency, it is well beforehand.

The advent of VL has helped revolutionize endotracheal intubation and led to significant improvements in patient safety as a result. Although it may be tempting to question the usefulness of DL, it should not be considered irrelevant and discarded. Both VL and DL are useful clinical techniques for facilitating endotracheal intubation, each with its respective risks and benefits, that should be learned and appreciated by all anesthesia providers. Although VL may be more advantageous than DL in some respects for novices, both approaches can provide significant educational opportunities and should be learned. Those seeking to incorporate VL into their current practices should review the particulars of and routinely practice with their respective VL devices to help ensure successful future use. Although VL represents the next step for laryngoscopy, it has not yet replaced DL as the singular viable option for anesthesia providers. Rather, VL and DL should be viewed as separate, unique clinical skills that should be mastered to maximize clinical success and patient safety.