DL vs. VL

A 2023 NEJM article reports the results of a large (n=1417) multicenter RCT. The primary outcome was successful intubation on the first attempt. The secondary outcome was severe complications. 91.5% of patients were intubated by EM or ICU staff. The trial was stopped at the first pre-planned interim analysis because the primary outcome was met and showed superiority of VL over DL. There was no difference in secondary outcomes.

Is the primary outcome clinically relevant? Look at supplement pages 33 and 36, which shows that for providers who were experienced at DL there was no difference in the primary outcome. Experienced means >100 prior intubations with DL. Is there a scenario where DL is useful? If so, we should practice it since we need to be the best at intubating in challenging situations? Do DL skills atrophy once acquired if you stop practicing?