In the Ongoing Debate, Its Training Over Tools for Laryngoscopy & Intubation
New Article Review
Can Anything Be More Tiring Than the Endless DL vs. VL Debate?
That’s why this new study by Mustafa Öcal, “The role of video and direct laryngoscopy in medical student intubation training: a comparative study on success rates and learning curves”, is such a breath of fresh air.
It shifts the focus away from devices and back onto learning, where it belongs. And it echoes what most experienced airway educators already know (assuming you’re looking at the full body of evidence rather than cherry-picking the studies that support your bias): VL may give you a head start, but with just a bit of practice, DL catches up.
The message is refreshingly clear—it’s not the device, it’s the training.
In this study, medical students did better with VL right out of the gate—faster, more successful intubations on their first tries. But by the third attempt, those using DL had caught up. Honestly, this study just confirms what common sense (and experience) already tells us: it’s not the blade, it’s the reps. Practice matters. The more you do it, the better you get (and yes), that includes DL.
Key Takeaways from the Study:
- 📈 VL has the edge early on — Students using VL had significantly higher first- and second-attempt success rates and faster intubation times.
- ⏱️ By the third try, DL catches up — Success rates and times between DL and VL were no longer significantly different by the third attempt.
- 🔁 DL improves faster with practice — DL users showed a steeper learning curve, with rapid gains in both speed and accuracy.
- 💡 VL motivates, DL builds depth — VL may boost early confidence, but DL fosters long-term competence essential for real-world unpredictability.
- 🧠 Training matters more than tools — The strongest predictor of success wasn’t which laryngoscope students used—it was how many times they practiced.
To see this only as a suggestion that we should still be training with DL is to miss the point. The results suggest this is about how DL supports learning and the trajectory of long-term skill development, and I’d argue that the time spent struggling with direct laryngoscopy (DL) during training isn’t a drawback, it’s part of the value. That steeper, more demanding learning curve may build deeper, more transferable skills. DL requires precise alignment, spatial awareness, and a nuanced understanding of airway anatomy. It forces learners to engage directly with tissue planes, hand-eye coordination, and problem-solving on their own under pressure. These aren’t just DL-specific skills, they’re foundational to all forms of airway management, including video laryngoscopy (VL).
Struggling with DL may hardwire the very motor and cognitive pathways that make someone better at VL down the line. When you learn under difficulty, you retain more, adapt faster, and develop the kind of confidence that can’t be shortcut. So yes, while VL may feel like the quicker win, the longer road with DL may pave the way for deeper expertise across both techniques.
🔑 Take-home message: While VL offers a gentler on-ramp for beginners, DL catches up quickly when learners are given the time and repetition needed to improve. The real determinant of skill is not the tool, but the training.
As always, mastery isn’t about the device, it’s about doing the work.
I still firmly believe both tools belong in every airway training program. Not because VL doesn’t have incredible advantages (it does) but because context and experience matter. There’s no one-size-fits-all solution for every provider, every setting, or every patient.
So let’s stop arguing, and keep practicing (with both of course).
Study Overview
Here’s a quick synopsis of the study methodology:
Study Design:
A mannequin-based, randomized study involving 130 medical students with no prior intubation experience.
Training:
Participants received a 30-minute didactic session covering the use of both direct laryngoscopy (DL) and video laryngoscopy (VL), followed by one hour of hands-on practice using normal airway mannequins.
Devices Used:
- DL: Standard Macintosh blade (size 3)
- VL: McGrath video laryngoscope with a size 3 Macintosh blade
Procedure:
Each student attempted intubation with both DL and VL across two airway scenarios.
- Three attempts per device were allowed.
- Maximum time per attempt: 3 minutes
- Success = successful intubation within 3 minutes
- Data collected: Success rates, intubation times, and learning curves
Analysis:
Statistical comparisons were made using chi-square, Fisher’s exact, t-tests, and regression analysis to evaluate performance trends over repeated attempts.
Strengths of the Study
- ✅ Large Sample Size
130 medical students across multiple academic years participated, providing a diverse and reasonably powered sample for educational research. - ✅ Direct Head-to-Head Comparison
Both VL (McGrath) and DL (Macintosh) were tested under the same conditions on the same mannequins, allowing for a clear comparative analysis. - ✅ Randomized Design
Participants were randomly assigned to start with either DL or VL, minimizing order effects and bias in performance outcomes. - ✅ Objective, Quantifiable Metrics
Success rates and intubation times were measured with clear thresholds (e.g., 3-minute cutoff), allowing for clean statistical comparisons. - ✅ Focus on Novice Learners
The study captures how beginners learn and progress—ideal for informing curriculum design in medical education. - ✅ Analysis of Learning Curves
By measuring across three attempts, the study provides insight into how performance changes over time, not just static snapshots.
Weaknesses of the Study
- ⚠️ Mannequin-Based Simulation Only
Findings may not generalize to real-world conditions where anatomy, secretions, time pressure, and patient variability play major roles. - ⚠️ Short Training Exposure
Students received just one hour of hands-on practice before being tested—this may not reflect the true potential of longer-term learning or skill retention. - ⚠️ No Long-Term Follow-Up
We don’t know how skills persisted over time, or whether initial VL success translated into better real-world performance later on. - ⚠️ Single Institution, Limited Diversity
All the students were from one university in Turkey. Broader applicability would benefit from multicenter or international replication. - ⚠️ Novice-Only Population
While great for understanding how learners develop, it doesn’t tell us how experienced providers perform or benefit from different devices.
The Bottom Line
This study reinforces that while video laryngoscopy (VL) offers higher initial success rates and faster performance among novice learners, direct laryngoscopy (DL) demonstrates a steeper learning curve and comparable outcomes with just a few additional attempts. The key determinant of intubation success is not the device, but deliberate practice. Effective airway training programs should incorporate both techniques, leveraging VL for early confidence while using DL to build foundational, transferable skills that support long-term clinical competence.
