Direct vs Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study.



Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways.


We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016-December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI).


Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts.


Analysis of the NEAR database demonstrates higher first-pass success with VL compared to DL in patients with predicted or anatomically difficult airways, and reduced rate of esophageal intubations and vomiting.





Published Version (Please cite this version)


Publication Info

Ruderman, Brandon T, Martina Mali, Amy H Kaji, Robert Kilgo, Susan Watts, Radosveta Wells, Alexander T Limkakeng, Joseph B Borawski, et al. (2022). Direct vs Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study. The western journal of emergency medicine, 23(5). pp. 706–715. 10.5811/westjem.2022.6.55551 Retrieved from

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Brandon T Ruderman

Assistant Professor of Emergency Medicine

Brandon Ruderman, MD, FACEP is an Assistant Professor in the Department of Emergency Medicine at Duke University School of Medicine. He graduated cum laude with distinction from Duke University with a Bachelor's of Science in Biology and a Certificate in Genome Sciences and Policy. He received his medical degree from the University of Rochester School of Medicine and Dentistry, where he also received the Marvin J. Hoffman International Medicine Award for a research project in Peru as well as the Society for Academic Emergency Medicine Medical Student Excellence in Emergency Medicine Award. He completed his residency training in Emergency Medicine at Duke University Medical Center, followed by a fellowship in Emergency Ultrasound at Duke. 

Dr. Ruderman joined Duke Emergency Medicine Faculty in 2020 after his fellowship, and his primary interests include medical student and resident ultrasound education, simulation, exploring novel applications of point-of-care ultrasound, and emergency airway research. He was a finalist in the 2018 American College of Emergency Physicians Research Forum Best Resident Abstract for his research comparing video laryngoscopy to direct laryngoscopy in patients with difficult airways. He has served in numerous roles as one of the Duke Emergency Ultrasound Faculty, including mentoring several medical students and residents, and as the Ultrasound Course Director for the Acute Care course for fourth year students at Duke University School of Medicine.


Alexander Tan Limkakeng

Professor of Emergency Medicine

Dr. Alexander T. Limkakeng, Jr., MD, MHSc, FACEP is a Professor of Emergency Medicine, Vice Chair of Clinical Research, Director of the Acute Care Research Team, and Director of the Resident Research Fellowship for the Department of Emergency Medicine in the Duke University School of Medicine in Durham, North Carolina.

Dr. Limkakeng has served as chair of the American College of Emergency Physicians (ACEP) Research Committee, and been the Course Director of the ACEP Research Forum from 2016-2018, the largest emergency medical research platform in the nation. He is also the Assistant Director of ACEP’s Emergency Medicine Basic Research Skills course. He was elected to the Nominating Committee of the Society of Academic Emergency Medicine.

As a researcher, Dr. Limkakeng has led multiple clinical trials and interdepartmental sponsored projects and is author on over 100 peer-reviewed manuscripts. These include studies in emergency conditions such as COVID-19, traumatic brain injury, hypertension, heart failure, thrombosis, stroke, envenomations, and septic shock. His research has been funded by grants and contracts totaling over $9 million dollars. He has lectured internationally on acute coronary syndrome, responsible conduct of research, design of clinical trials, and precision medicine in emergency care. He has led Duke’s involvement in NIH-funded research networks and in industry-funded work that led to FDA approval for multiple high-sensitivity cardiac troponin assays and point-of-care COVID-19 diagnostic tests. He has servesd as Co-PI for the Duke U24 Hub in the NIH Early Phase Pain Investigation Clinical Network (EPPIC-Net) (1U24NS114416) and now serves as a co-PI on the Duke U24 Hub award (1U24NS129498) in the NIH Strategies to Innovate Emergency Care Clinical Trials (SIREN) Network and in the NIH NINDS Strokenet network (1U24NS135250)

His personal research interest is finding new ways to diagnose acute coronary syndrome. In particular, he is interested in novel biomarkers and precision medicine approaches to this problem. The common element throughout this work is a focus on time-sensitive health conditions.

Joseph Brian Borawski

Assistant Professor of Emergency Medicine

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