Background <p>Videolaryngoscopy has significantly improved the management of unanticipated difficult airways and replaced other intubation techniques. The goal of this study was to identify the indications for using videolaryngoscopy and fiberoptic bronchoscopy for adult patients, where direct laryngoscopy is the standard intubation technique.</p> Methods <p>Over a one-year period from January to December 2018, anesthesiologists were surveyed on their reasons for using a videolaryngoscope or fiberoptic bronchoscope for tracheal intubations. Additionally, retrospective data on all direct laryngoscopy intubations were collected for the same period from the anesthesia information management system.</p> Results <p>Out of 6251 tracheal intubations with direct laryngoscopy and 502 with videolaryngoscopy or fiberoptic bronchoscopy, data from 450 (89.6%) cases were collected. We excluded 46 cases where videolaryngoscopy and fiberoptic bronchoscopy were used for non-airway management reasons, resulting in 404 cases for analysis. Videolaryngoscopy was initially used in 356 (88.1%) patients. The primary reasons for using videolaryngoscopy or fiberoptic bronchoscopy were anticipated difficult intubation (218, 54.0%) and cervical pathology (109, 27.0%). Among the 42 cases of unanticipated failed direct laryngoscopy, videolaryngoscopy was used in 41 cases and fiberoptic bronchoscopy in 1 case. The overall rate of unanticipated failed direct laryngoscopy was 0.7%.</p> Conclusions <p>The routine use of videolaryngoscopy and fiberoptic bronchoscopy for anticipated difficult tracheal intubations led to a very low incidence of unanticipated failed tracheal intubations with direct laryngoscopy. Therefore, routinely using more expensive videolaryngoscopes for all intubations would prevent only very small numbers of unanticipated failed direct laryngoscopic intubations and is not financially justified.</p>