The objective of the study is to compare the efficacy of video laryngoscopy (VL) to direct laryngoscopy (DL) on the first pass intubation success of patients with difficult airway characteristics (DACs) in the emergency department (ED). Over a 6-year period, between July 1 2007 and June 30 2013, all intubations performed in an academic ED were recorded in a continuous quality improvement (CQI) database by the operators. The CQI form included information such as patient demographics, operator level of training, device(s) used, number of attempts and outcome of each attempt. In addition, operators performed a difficult airway assessment and noted the presence or absence of the following difficult airway characteristics (DACs): airway edema, cervical immobility, facial/neck trauma, large tongue, obesity, short neck, small mandible, and blood or vomit in the airway. Patients <18 years of age and those not intubated by an emergency physician (EP) were excluded from the analysis. Multivariate regression models were developed to determine the effect of device type (VL or DL) on first pass intubation success as the number of DACs increased. A total of 2,423 intubations were included in this study. First pass success by the number of DACs was as follows in the VL and DL groups, respectively: no DACs [90.8 % (95 % CI 87.5-93.4) vs. 82.0 % (95 % CI 78.0-85.5)]; one DAC [85.1 % (95 % CI 81.2-88.5 %) vs. 69.4 % (95 % CI 63.9-74.5 %)]; two DACs [(80.5 % (95 % CI 74.7-85.6 %) vs. 65.8 % (95 % CI 57.6-73.3 %)]; three or more DACs [68.9 % (95 % CI 63.8-73.7 %) vs. 54.1 % (95 % CI 46.3-61.8 %)]. After adjusting for potential confounders, VL was associated with higher odds of first pass success for patients with no DACs (aOR 2.0, 95 % CI 1.2-3.3), one DAC (aOR 3.2, 95 % CI 1.9-5.6), two DACs (aOR 2.3, 95 % CI 1.1-4.9), and three or more DACs (aOR 2.9, 95 % CI 1.5-5.5). In patients with DACs, VL was associated with a higher first pass success than DL. VL is recommended as the primary intubating device for patients with predicted difficult airways in the ED.