Comparison of Video Versus Direct Laryngoscopy: A Prospective Prehospital Air Medical Services Study

Published:December 04, 2020DOI:


      • Glottic visualization improved using videolaryngoscopy (VL), especially among patients with Cormack-Lehane (CL) grades 3 and 4 on direct laryngoscopy (DL).
      • Twenty-four patients had a CL grade 1 to 2 view with DL compared with 45 patients with VL.
      • Of the 25 patients with CL grade 3 and 4 view on DL, 22 were converted to grade 1 and 2 with VL.
      • The overall success rate with VL was 96%, and the first-pass success rate was 71%.
      • VL was functional 100% of the time, with a good or excellent image 98% of the time.



      Videolaryngoscopy (VL) in the prehospital setting remains controversial, with conflicting data on its utility. We compared C-MAC VL (Karl Storz, Tuttlingen, Germany) versus direct laryngoscopy (DL) in the prehospital setting, recording the grade of the glottic view, first pass success (FPS), overall success, and equipment functionality.


      We conducted a prospective observational study with a convenience sample of 49 adult patients who were intubated by flight crew nurses and paramedics using the C-MAC videolaryngoscope from April to November 2013. We compared Cormack-Lehane (CL) grades of view for DL and VL, intubation success rates, and equipment functionality.


      CL grades 1 or 2 were obtained with 24 patients (49%) with DL and 45 patients (92%) with VL. Of the 25 patients (51%) who had a CL grade 3 or 4 view on DL, 22 of those patients (88%) converted to a CL grade 1 or 2 with VL (P < .001). There was an overall success rate of 96% and an FPS rate of 71%. The C-MAC videolaryngoscope was functional during intubation 100% of the time.


      VL improved glottic visualization compared with DL. The FPS and overall intubation success rates were similar to other published prehospital studies using VL. The C-MAC provided reliable, high-quality video despite demanding prehospital conditions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Air Medical Journal
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wang HE
        • Mann NC
        • Mears G
        • Jacobson K
        • Yealy DM
        Out-of-hospital airway management in the United States.
        Resuscitation. 2011; 82: 378-385
        • Wang HE
        • Yealy DM
        How many attempts are required to accomplish out-of-hospital endotracheal intubation.
        Acad Emerg Med. 2006; 13: 372-377
        • Naito H
        • Guyette FX
        • Martin-Gill C
        • Callaway CW
        Video laryngoscopic techniques associated with intubation success in a helicopter emergency medical service system.
        Prehosp Emerg Care. 2016; 20: 333-342
        • Cobas MA
        • De la Peña MA
        • Manning R
        • Candiotti K
        • Varon AJ
        Prehospital intubations and mortality: a level 1 trauma center perspective.
        Anesth Analg. 2009; 109: 489-493
        • Timmermann A
        • Eich C
        • Russo SG
        • et al.
        Prehospital airway management: a prospective evaluation of anaesthesia trained emergency physicians.
        Resuscitation. 2006; 70: 179-185
        • 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: 636-641
        • De Jong A
        • Molinari N
        • Conseil M
        • et al.
        Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis.
        Intensive Care Med. 2014; 40: 629-639
        • Griesdale DE
        • Liu D
        • McKinney J
        • Choi PT
        Glidescope video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis.
        Can J Anaesth. 2012; 59: 41-52
        • Brown 3rd, CA
        • Bair AE
        • Pallin DJ
        • Laurin EG
        • Walls RM
        • National Emergency Airway Registry (NEAR) Investigators
        Improved glottic exposure with the video Macintosh laryngoscope in adult emergency department tracheal intubations.
        Ann Emerg Med. 2010; 56: 83-88
        • Carlson JN
        • Quintero J
        • Guyette FX
        • Callaway CW
        • Menegazzi JJ
        Variables associated with successful intubation attempts using video laryngoscopy: a preliminary report in a helicopter emergency medical service.
        Prehosp Emerg Care. 2012; 16: 293-298
        • Sakles JC
        • Javedani PP
        • Chase E
        • Garst-Orozco J
        • Guillen-Rodriguez JM
        The use of a video laryngoscope by emergency medicine residents is associated with a reduction in esophageal intubations in the emergency department.
        Acad Emerg Med. 2015; 22: 700-707
        • Wayne MA
        • McDonnell M
        Comparison of traditional versus video laryngoscopy in out-of-hospital tracheal intubation.
        Prehosp Emerg Care. 2010; 14: 278-282
        • Nouruzi-Sedeh P
        • Schumann M
        • Groeben H
        Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.
        Anesthesiology. 2009; 110: 32-37
        • Sakles JC
        • Chiu S
        • Mosier J
        • Walker C
        • Stolz U
        The importance of first pass success when performing orotracheal intubation in the emergency department.
        Acad Emerg Med. 2013; 20: 71-78
        • Sun DA
        • Warriner CB
        • Parsons DG
        • Klein R
        • Umedaly HS
        • Moult M
        The GlideScope video laryngoscope: randomized clinical trial in 200 patients.
        Br J Anaesth. 2005; 94: 381-384
        • Cooper RM
        • Pacey JA
        • Bishop MJ
        • McCluskey SA
        Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients.
        Can J Anaesth. 2005; 52: 191-198
        • Rai MR
        • Dering A
        • Verghese C
        The Glidescope system: a clinical assessment of performance.
        Anaesthesia. 2005; 60: 60-64
        • Savino PB
        • Reichelderfer S
        • Mercer MP
        • Wang RC
        • Sporer KA
        Direct versus video laryngoscopy for prehospital intubation: a systematic review and meta-analysis.
        Acad Emerg Med. 2017; 24: 1018-1026
        • Deakin CD
        The C-MAC videolaryngoscope for prehospital emergency intubation.
        Emerg Med J. 2011; 28: 643
        • Brown CA
        • Kaji AH
        • Fantegrossi A
        • et al.
        Video laryngoscopy compared to augmented direct laryngoscopy in adult emergency department tracheal intubations: a National Emergency Airway Registry (NEAR) Study.
        Acad Emerg Med. 2020; 27: 100-108
        • Bjoernsen LP
        • Parquette BT
        • Lindsay MB
        Prehospital use of video laryngoscope by an air medical crew.
        Air Med J. 2008; 27: 242-244
        • Cavus E
        • Callies A
        • Doerges V
        • et al.
        The C-MAC videolaryngoscope for prehospital emergency intubation: a prospective, multicentre, observational study.
        Emerg Med J. 2011; 28: 650-653
        • Mort TC
        Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts.
        Anesth Analg. 2004; 99 (table of contents): 607-613
        • Smereka J
        • Ladny JR
        • Naylor A
        • Ruetzler K
        • Szarpak L
        C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: a manikin trial.
        Am J Emerg Med. 2017; 35: 1142-1146
        • Kaplan A
        • Göksu E
        • Yıldız G
        • Kılıç T
        Comparison of the C-MAC videolaryngoscope and rigid fiberscope with direct laryngoscopy in easy and difficult airway scenarios: a manikin study.
        J Emerg Med. 2016; 50: e107-e114
        • Yildirim A
        • Kiraz HA
        • Ağaoğlu İ
        • Akdur O
        Comparison of Macintosh, McCoy and C-MAC D-Blade video laryngoscope intubation by prehospital emergency health workers: a simulation study.
        Intern Emerg Med. 2017; 12: 91-97
        • Hossfeld B
        • Frey K
        • Doerges V
        • Lampl L
        • Helm M
        Improvement in glottic visualisation by using the C-MAC PM video laryngoscope as a first-line device for out-of-hospital emergency tracheal intubation: an observational study.
        Eur J Anaesthesiol. 2015; 32: 425-431
        • Cavus E
        • Janssen S
        • Reifferscheid F
        • et al.
        Videolaryngoscopy for physician-based, prehospital emergency intubation: a prospective, randomized, multicenter comparison of different blade types using A.P. Advance, C-MAC System, and KingVision.
        Anesth Analg. 2018; 126: 1565-1574
        • Suppan L
        • Tramèr MR
        • Niquille M
        • Grosgurin O
        • Marti C
        Alternative intubation techniques vs Macintosh laryngoscopy in patients with cervical spine immobilization: systematic review and meta-analysis of randomized controlled trials.
        Br J Anaesth. 2016; 116: 27-36
        • Jarvis JL
        • McClure SF
        • Johns D
        EMS intubation improves with King Vision video laryngoscopy.
        Prehosp Emerg Care. 2015; 19: 482-489
        • Sakles JC
        • Patanwala AE
        • Mosier JM
        • Dicken JM
        Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department.
        Intern Emerg Med. 2014; 9: 93-98
        • Burnett AM
        • Frascone RJ
        • Wewerka SS
        • et al.
        Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial.
        Prehosp Emerg Care. 2014; 18: 231-238
        • Guyette FX
        • Farrell K
        • Carlson JN
        • Callaway CW
        • Phrampus P
        Comparison of video laryngoscopy and direct laryngoscopy in a critical care transport service.
        Prehosp Emerg Care. 2013; 17: 149-154
        • Ducharme S
        • Kramer B
        • Gelbart D
        • Colleran C
        • Risavi B
        • Carlson JN
        A pilot, prospective, randomized trial of video versus direct laryngoscopy for paramedic endotracheal intubation.
        Resuscitation. 2017; 114: 121-126
        • Cormack RS
        • Lehane J
        Difficult tracheal intubation in obstetrics.
        Anaesthesia. 1984; 39: 1105-1111