The hidden story in the VL-DL discussion is that DL skills have deteriorated significantly from their historical benchmark standard. There is no question that VL is superior to bad DL. To date there is little evidence that VL is better than optimal DL (Bimanual laryngoscopy) using simple adjuncts such as a bougie. As we've espoused before its less about the device and more about the hands that hold it that make a difference. In our air medical program (Lifeflight) Critical Care Paramedics manage the airway and our first pass success rate using DL as our primary go to is 90% with a low incidence hypotension and hypoxemia. It's the little stuff that makes a difference. Now don't get me wrong I love VL in particular Mac VL. Just remember that good DL can be great.
In AIME we teach 3:2:1, three things to do with two hands on first attempt to facilitate first pass success. This includes 1. head lift 2. ELM and 3. use of a bougie. As soon as the right hand moves from facilitating mouth opening (using a cross-finger technique), it moves to the occiput to perform a head lift. People tend to overlook head lift once they have committed to ear-sternum positioning. Head-elevated laryngoscopy is a pearl that Rich Levitan taught us almost 15 years ago.
Levitan RM, Mechem CC, Ochroch EA, Shofer FS, Hollander JE. Head-elevated laryngoscopy position: improving laryngeal exposure during laryngoscopy by increasing head elevation. Ann Emerg Med. 2003 Mar;41(3):322-30. PubMed PMID: 12605198.
I used to think ithis cognitive oversight was compounded by the fact that most manikins don't reward the head lift with an improved view. While I tend to ignore most manikin studies a recent paper demonstrated this maneuver can also save our plastic friends.
Stein C, Gerber L, Curtin D, Oberem N, Wells M. A Comparison of Three Maneuvers and Their Effect on Laryngoscopic View, Time to Intubate, and Intubation Outcome by Novice Intubators in a Simulated Airway. Prehosp Disaster Med. 2017 Apr 6:1-5. doi: 10.1017/S1049023X17006392. [Epub ahead of print] PubMed PMID: 28382880.
Remember though, head lift can be a powerful DL intervention on humans live and cadaveric...