DEVICE
Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults
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Overview
In ED and ICU intubation, video laryngoscopy raised first-pass success compared with direct laryngoscopy.
Clinical takeaway
DEVICE supports reaching for a video laryngoscope first in critically ill adults: first-attempt success was higher, while severe peri-intubation complications were similar.
Key result
First-attempt success was 85.1% with video laryngoscopy vs 70.8% with direct laryngoscopy (absolute risk difference 14.3 percentage points; 95% CI 9.9-18.7; p<0.001).
Practice impact
Prefer video laryngoscopy for emergency tracheal intubation in the ED or ICU.
Evidence
Study design
Multicenter randomized trial at 17 emergency departments and intensive care units.
Enrollment
1,417
Follow-up
First-attempt intubation success and severe complications during intubation.
Geography
Not listed
Clinical question
Does video laryngoscopy increase first-attempt tracheal intubation success compared with direct laryngoscopy in critically ill adults?
Population
- Critically ill adults undergoing tracheal intubation in an emergency department or ICU.
- Most intubations (91.5%) were performed by an emergency medicine resident or a critical care fellow.
Intervention
Video laryngoscope.
Comparator
Direct laryngoscope.
Primary outcome
Successful intubation on the first attempt.
Video laryngoscopy produced more first-attempt successes than direct laryngoscopy in ED and ICU intubation.
Absolute risk difference / 14.3 / 95% CI 9.9-18.7 / p<0.001
Key results
- First-attempt success: 85.1% with video laryngoscopy vs 70.8% with direct laryngoscopy; absolute risk difference 14.3 percentage points (95% CI 9.9-18.7; p<0.001).
- The trial was stopped for efficacy at the single preplanned interim analysis.
- Severe complications during intubation were similar (21.4% vs 20.9%).
- Esophageal intubation, dental injury, and aspiration were similar in the two groups.
Harms
- Severe complications during intubation (severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death) were similar.
- Esophageal intubation, injury to the teeth, and aspiration were similar in the two groups.
Clinical Use
Practice impact
- Prefer video laryngoscopy for emergency tracheal intubation in the ED or ICU.
Applicability
- Most applicable to critically ill adults intubated in an emergency department or ICU, often by a resident or fellow.
Limitations
- The trial was stopped for efficacy at a single preplanned interim analysis.
- Most intubations were performed by an emergency medicine resident or a critical care fellow.
- Higher first-pass success did not reduce the reported rate of severe peri-intubation complications.
Common misinterpretations
- DEVICE shows better first-pass success, not fewer severe complications.
- The result applies to emergency ED and ICU intubation, not to elective operating-room airway management.
Related evidence
Citation
Prekker ME, Driver BE, Trent SA, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023;389(5):418-429. doi:10.1056/NEJMoa2301601
Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope.
- PMID
- 37326325