Critical Care Alert, Critical Care, Airway

Critical Care Alert: Video v. Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults: The DEVICE Trial

ARTICLE: Prekker ME, Driver BE, Trent SA, et al. for DEVICE Investigators and the Pragmatic Critical Care Research Group. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023;389(5):418-429.

OBJECTIVE: To determine if video laryngoscopy compared with direct laryngoscopy increases the likelihood of successful tracheal intubation on the first attempt among critically ill adults.

Endotracheal intubation, a potentially life-saving procedure commonly performed during the care of critically ill patients, requires precision and accuracy as failure to intubate on the first attempt is associated with increased risk of life-threatening complications.1

The two types of devices used to perform tracheal intubation are direct and video laryngoscopes. A direct laryngoscope consists of a handle, a blade, and a light and allows for direct visualization of the vocal cords through the mouth. A video laryngoscope includes the same components but is also equipped with a camera positioned in the distal half of the blade that transmits images to a screen.2 The screen allows for indirect visualization of the vocal cords which a clinician can use to guide the endotracheal tube into the correct position. Although the majority (~80%)3 of intubations in EDs and ICUs worldwide are performed utilizing a direct laryngoscope, the use of video laryngoscopy has increased in recent years, particularly due to guidelines developed during the Covid-19 pandemic that sought to limit viral transmission by increasing the distance from the patient’s mouth to the operator.4

Several trials have been conducted to compare the outcomes of video versus direct laryngoscopy among critically ill adults undergoing tracheal intubation, most of which occur in the operating room. These trials showed differing results, including better outcomes with a video laryngoscope,5 better outcomes with a direct laryngoscope6 and no significant differences in outcomes between the two types.7 Given the varying settings and patient populations included in these studies, it is unclear how these results apply to critically ill patients in the ED and ICU. The goal of the DEVICE trial was to investigate whether the use of a video laryngoscope would result in a higher incidence of successful intubation on the first attempt in critically ill adults in this patient population.


  • Pragmatic, multicenter, unblinded, randomized, parallel group trial conducted at 17 sites, 7 EDs and 10 ICUs in 11 medical centers across the United States from March 2022 until November 2022
  • Patients were randomly assigned in a 1:1 ratio to undergo intubation with video laryngoscope or with direct laryngoscope. Assignments were placed in sequentially numbered opaque envelopes and remained concealed until after enrollment
  • Given the nature of the intervention, clinicians and research personnel were aware of the trial group assignments after randomization
  • A trained research personnel observed the intubation and collected data on the primary outcome (number of times a laryngoscope blade, a bougie, and an endotracheal tube entered the patient’s mouth), the duration of intubation and the vital signs (lowest O2 sat and systolic blood pressure) during the interval between induction of anesthesia and 2 minutes post-intubation
  • The operator reported a subjective assessment of anticipated difficulty of tracheal intubation before randomization and afterwards (easy, moderate, difficult), reported Cormack-Lehane grade of laryngeal view, reasons for failure to intubate if applicable, procedural complications (esophageal intubation, injury to the teeth, aspiration), and number of previous intubations operator had performed


  • Critically ill adults, age >= 18 years undergoing orotracheal intubation


  • Pregnant
  • Incarcerated or involuntarily detained
  • Immediate need for tracheal intubation that precluded randomization
  • Contraindication or indication for certain method as determined by operator


  • Successful intubation on the first attempt, defined as the placement of an endotracheal (ET) tube in the trachea with a single insertion of a laryngoscope blade into the mouth (use of bougie first was acceptable as long as both only required a single insertion)


  • The occurrence of any severe complications between induction and 2 minutes after intubation:
    • Severe hypoxemia, SaO2 <80%
    • Severe hypotension, SBP <65 mmHg
    • New or increased use of vasopressors
    • Cardiac arrest
    • Death



A total of 1420 patients (72.9%) were enrolled out of the 1947 patients that were eligible, and 1417 were included in final analysis. A total of 705 patients (49.8%) were assigned to the video laryngoscope group and 712 (50.2%) to the direct-laryngoscope group. Median age was 55 years, and 69.7% of the patients were intubated in the ED. The most common indications for intubation was altered mental status (45.3%) and acute respiratory failure (30.4%).

A total of 387 unique operators performed an intubation during the trial, with each one performing a median of two intubations. The vast majority (91.5%) of intubations were performed by an emergency medicine resident or a critical care fellow. They had performed a median of 50 prior intubations with the median proportion of those being with video laryngoscope was 0.69. Grade 1 view of the vocal cords was reported in 76.3% of the patients in the video-laryngoscope group, compared to 44.7% in the direct-laryngoscope group (absolute risk reduction [ARR], 31.6%; 95% confidence interval [CI], 26.7 to 36.6). The trial was stopped early because the prespecified stopping criterion for efficacy had been met. 

Primary Outcome
Successful intubation on the first attempt occurred in 600 out of 705 patients (85.1%) in the video-laryngoscope group and 504 out of 712 (70.8%) in the direct-laryngoscope group (ARR, 14.3%; 95% CI, 9.9 to 18.7; p<0.001). Among the operators who had performed fewer than 25 intubations, the ARR between the two groups was 26.1% (95% CI, 15.4 to 36.8). Among operators who had performed more than 100 intubations, the ARR was 5.9% (95% CI, −4.1 to 16.0).

Secondary Outcomes
A total of 151 patients (21.4%) in the video-laryngoscope group and 149 patients (20.9%) in the direct laryngoscope group had a severe complication during intubation (ARR, 0.5%; 95% CI, −3.9 to 4.9):

  • SaO2 <80% in 64 out of 658 (9.7%) in the video-laryngoscope group and 69 out of 659 (10.5%) in the direct-laryngoscope group (ARR, −0.7; 95% CI,−4.2 to 2.7)
  • SBP < 65 mmHg in 64 out of 624 (3.2%) in the video group and 29 out of 644 (4.5%) in the direct group (ARR, −1.3; 95% CI,−3.6 to 1.0)
  • New or increased use of vasopressors in 91 (12.9%) in video group and 87 (12.2%) in direct group (ARR, 0.7; 95% CI,−2.9 to 4.3)
  • Cardiac arrest not resulting in death in 2 (0.3%) in video group and 0 in direct group (ARR, 0.3; 95% CI,−0.3 to 0.8)
  • Cardiac arrest resulting in death in 1 (0.1%) in video group and 3 in direct group (0.4%) (ARR, −0.3; 95% CI,−1.0 to 0.4)


  • Because 97% of the operators had performed fewer than 250 previous tracheal intubations, these results might not be generalizable to operators with more experience
  • The brand of video laryngoscope and the shape of the blade was not standardized, thus it is unclear what brand or blade leads to best outcomes
  • The study was unblinded, thus clinicians and trial personnel were aware of the trial-group assignments
  • All intubations were performed in the ED or ICU and thus may not be generalizable to anesthesiologists in the operating room


When intubating critically ill patients in the ED or ICU, consider using video over direct laryngoscopy to improve the likelihood of successful first-pass tracheal intubation. This effect was more pronounced with inexperienced operators who likely benefited from the greater laryngeal visualization and real-time feedback from other clinicians that video laryngoscopy provides.


  1. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013;20(1):71–78.
  2. Berkow LC, Morey TE, Urdaneta F. The Technology of Video Laryngoscopy. Anesth Analg. 2018;126(5):1527–1534.
  3. Russotto V, Myatra SN, Laffey JG, et al. INTUBE Study Investigators (2021). Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021;325(12):1164–1172.
  4. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetist. Anaesthesia. 2020;75(6):785–799.
  5. Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: a randomized controlled trial. Crit Care Med. 2015;43(3):636–641.
  6. Trimmel H, Kreutziger J, Fitzka R, et al. Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial. Crit Care Med. 2016;44(7):e470–e476.
  7. Driver BE, Prekker ME, Moore JC, Schick AL, Reardon RF, Miner JR. Direct Versus Video Laryngoscopy Using the C-MAC for Tracheal Intubation in the Emergency Department, a Randomized Controlled Trial. Acad Emerg Med. 2016;23(4):433–439.

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