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To compare the complication rates of urgent endotracheal intubation (UEI) performed by pulmonary critical care medicine (PCCM) fellows and attending intensivists using a direct laryngoscope (DL) versus a video laryngoscope (VL) in a medical intensive care unit (MICU).We studied all UEIs performed from November 2008 through July 2012 in an 18-bed MICU in a university-affiliated hospital. All UEIs were performed by 15 PCCM fellows or attending intensivists using only the DL from November 2008 through February 2010 and the VL from March 2010 to July 2012. Throughout the entire study period, the UEI team leader recorded complications of the procedure using a standard data collection form immediately following the completion of the procedure. This permitted a comparison of complication rates between the DL and the VL.A total of 140 UEIs were performed using the DL and 252 using the VL. Using the DL, the esophageal intubation rate was 19% and the difficult intubation rate was 22%; using the VL, the esophageal intubation rate was 0.4% and the difficult intubation rate was 7%. There was no significant difference in the rate of severe hypotension, severe desaturation, aspiration, dental injury, airway injury, or death between the 2 groups.The use of the VL for UEI performed by PCCM fellows is associated with a reduction in the rate of esophageal intubation and difficult endotracheal intubation when compared to the use of the DL.