The mystique of direct laryngoscopy.

Direct laryngoscopy and intubation is easy to define and conceptually very simple. A short, rigid instrument deflects the tongue and jaw, enabling a direct line of sight to the larynx and placement of a tube into the trachea. Historically, laryngoscopy has been taught to all providers of emergency care and resuscitation. It is the predominant intubation method in emergency care and, despite the proliferation of alternative instruments, in anesthesia as well. Direct laryngoscopy for the purpose of intubation has an impressive success rate: 98–99 % in elective anesthesia and emergency cases.1–6 Few interventions in medicine can match this high success rate. The problem, however, is that when failure occurs, the consequence can be catastrophic if rescue ventilation cannot be achieved or if rescue intubation cannot be done quickly. For too many patients in emergency settings, intubation delays caused by repeated intubation attempts involve marked hypoxia, bradycardia, and cardiac arrest.7 For a small percentage of patients, direct laryngoscopy cannot work because of mechanical issues with mouth opening, severe problems of neck position, or unpredicted pathology at the epiglottis or base of the tongue.8