Video Laryngoscopy Solved One Problem — And Revealed Another

By TTC admin
For years, the debate in airway management was simple: does video laryngoscopy (VL) beat direct laryngoscopy (DL)? According to recent research, that debate is over. VL consistently delivers clearer views of the glottis and higher first-pass intubation success rates than DL. But according to Dr. Sean Runnels, Associate Professor of Anesthesiology at the University of Utah School of Medicine and CEO of TTC Medical, "best in class" doesn't mean the job is finished.

What the Data Actually Shows

Two large, well-conducted randomized controlled trials reinforced VL's superiority over DL. One study of critically ill patients in emergency departments and ICUs found meaningfully higher first-pass success with VL compared to DL. A second study in operating room settings found a similar pattern, with VL outperforming DL by a wide margin. A comprehensive meta-analysis backed up both findings. So VL wins. But it doesn't win every time — and the reason it sometimes fails is the real story.

The Real Insight: It's Not About Seeing Anymore

Here's the finding that should reshape how the industry thinks about airway devices: when VL fails, it's rarely because clinicians can't see the airway. It's because they can't get the tube where it needs to go. Across multiple studies, the majority of VL intubation failures happened despite a clear or adequate view of the glottis on screen. In other words, visualization wasn't the bottleneck — getting the tube from the mouth into the trachea was. This is a meaningful shift. Direct laryngoscopy's dominant failure mode was always poor visualization. Video laryngoscopy essentially solved that problem. But in doing so, it exposed a second, previously under-recognized challenge that had been hiding behind the visualization problem all along: tracheal access.

Why "Tracheal Access" Doesn't Have a Playbook Yet

One of the more striking points raised is how little standardized language or classification exists for this problem. Glottic visualization has established scoring systems clinicians reference constantly. Tracheal access has nothing comparable — no agreed-upon terminology, no classification system, no widely accepted way to measure or study it. That absence isn't a minor detail. It suggests the field hasn't yet treated tracheal access as its own distinct clinical problem — one deserving the same rigor that visualization received during the DL era. Some of the open questions worth asking:
  • Are current intubation pathways still built around the traditional three-axis alignment model, or does the more modern serpentine, two-curve airway geometry better reflect what clinicians are actually navigating?
  • How much force is really being applied to airway tissue by different tracheal access tools?
  • Is a rigid metal stylet or blade genuinely the right tool for navigating a curved pathway?

What This Means for the Next Era of Airway Management

The direct laryngoscopy era was defined by the pursuit of better visualization. The video laryngoscopy era, now firmly established, will likely be defined by the pursuit of better tracheal access — new tools, new terminology, and new techniques built specifically to solve the problem that VL uncovered. At TTC Medical, this is exactly the challenge we're focused on. Understanding the forces and geometry involved in tracheal access isn't just an academic exercise — it's the next frontier in making intubation safer and more predictable for every patient, every time. Read the full clinical commentary by Dr. Sean Runnels on Anesthesiology News: Video Laryngoscope–Based Intubations: Superiority Brings Evidence of a New Failure Mode

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