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In the critically ill undergoing urgent endotracheal intubation by direct laryngoscopy, multiple attempts are often required with a higher complication rate due to the urgency, uncontrolled setting, comorbidities, and variability in expertise of operators. We hypothesized that Glidescope video laryngoscopy would be superior to direct laryngoscopy during urgent endotracheal intubation.Single-center prospective randomized controlled trial.Beth Israel Medical Center, an 856-bed urban teaching hospital with a 16-bed closed medical ICU.Of 153 consecutive patients undergoing urgent endotracheal intubation by pulmonary and critical care medicine fellows, 117 met inclusion criteria.Patients undergoing urgent endotracheal intubation were randomized to Glidescope video laryngoscopy or direct laryngoscopy as the primary intubation device.The primary outcome measure was the rate of first-attempt success. Acute Physiology and Chronic Health Evaluation II scores were similar between groups (20.9 ± 8.2 vs 19.9 ± 7.9). First-attempt success was achieved in 74% of the Glidescope video laryngoscopy group compared with 40% in the direct laryngoscopy group (p < 0.001). All unsuccessful direct laryngoscopy patients were successfully intubated with Glidescope video laryngoscopy, 82% on the first attempt. There was no significant difference in rates of complications between direct laryngoscopy and Glidescope video laryngoscopy: esophageal intubations (7% vs 0%; p = 0.05), aspiration events (7% vs 9%; p = 0.69), desaturation (8% vs 4%; p = 0.27), and hypotension (13% vs 11%; p = 0.64).Glidescope video laryngoscopy improves the first-attempt success rate during urgent endotracheal intubation performed by pulmonary and critical care medicine fellows when compared with direct laryngoscopy.