Direct (DL) vs Video Laryngoscopy (VL) for Intubation? DEVICE Trial

Your patient needs an airway. What is your go-to tool for endotracheal intubation? Do you reach for direct laryngoscopy (DL) and just get it over with? Or do you wait until the whole setup gets brought into the room to attempt a video laryngoscopy (VL)? The debate of DL vs. VL for intubation has persisted longer than I have been in medicine. I’m not sure there’s one answer to the question but what is overall best for our patients?

Introducing the DEVICE Trial and a Disclaimer

That’s what these authors attempted to find out in the DEVICE trial. This study was published in the New England Journal of Medicine on June 16, 2023. For the sake of disclosures, I personally know several of the authors of the study as the place where I trained is amongst the 11 institutions where they enrolled patients. One of these authors was a key mentor of mine in managing airways. I owe him a ton. I would not have my current job had it not been for another one of the investigators.

A definite hat tip to the authors, but especially those to whom I owe so much they trained me. I guess there may be some bias from me in taking apart this paper. As always, read these data for yourself as this is not medical advice. Thankfully, this article is free for your to download. Links to the paper are listed below.

My Personal Relationship with DL and VL for Intubation

My practice when it comes to intubations has gone through several phases. The first was during medical school in another country. I spent a considerable amount of time in the operating room and I was blessed to work with anesthesiologists who taught me how to manage airways. I do not believe that VL was even available so DL was the tool for every intubation. The best part is that I was not allowed to even attempt an intubation until I was able to appropriately bag patients. In residency, we had the luxury of using VL rather than DL for almost every intubation. This allowed the attending physicians to clearly supervise what we were visualizing. This also helped them coach our hand movements and angles, amongst other things. DL was the tool during codes if VL was too far away and the patient needed intubation.

During fellowship at one of the institutions participating in this trial, I was trained predominantly using DL. This was amazing training. Amongst my favorite parts of my training was that I carried the airway pager along with the anesthesiology chief. Both the anesthesiology chiefs and I would respond to the airway request, assess the patient, and make a shared decision on how to proceed. The part that made this so neat was that we carried around airway bags which had medications and the tools necessary to secure the airway. In order to advance the training, we would safely take different approaches on each airway to master the numerous tools at our disposal to intubate the patient. Out of all these tools, VL was used the least.

During these almost 6 years that I have been in private practice, I almost exclusively use VL rather than DL for intubation. We are blessed in that the time it takes for a device to arrive anywhere in the hospital that it is needed is the same amount of time it would take to change the batteries on a DL handle that hasn’t been used in months. That last part is a joke but you get it.

Breaking Down the VL vs. DL for Intubation Trial

This study was a pragmatic, multicenter, unblinded, randomized, parallel-group trial in critically ill patients. Either VL or DL for intubation. Note that they are not OR cases. These were all performed in either the ED or ICU. By the way, for those wondering, pragmatic in this settings means to help us decide between two options as opposed to testing hypotheses. It is unblinded because, well, you can’t blind the teams as to what tool they’re going to use. Since the patients needed to be randomized, something that usually takes some time to do, if they patient was really really crashing, they were excluded from the trial.

The gear used was straightforward. No rules on the brands, shapes of blades, nor sizes. If it was VL, the screen had to be used. If it was DL, well then obviously there were no screens. The second attempt, if needed, was dealers choice. There was someone in the room taking notes regarding the primary outcome and secondary outcomes.

Since these institutions are academic shops, almost 95% of the intubations were performed by either en emergency medicine resident or a critical care fellow. Looking at the characteristics of the operator and intubation procedure reminds me of why I am personally not in academics. I love managing airways. It is always challenging and deserves the utmost respect. About 2% of the intubations were performed by the attending. Almost all the rest were performed by the residents or fellows. They need to be trained, sure. But I’ll sit back in my community hospital and knock out my airways myself or with my APP’s.

Primary Outcome of using DL vs. VL for Intubation

The primary outcome of the DEVICE trial looking at VL vs. DL during intubation was a successful intubation on the first attempt. They ended up enrolling over 1400 patients. Just over 700 patients in each group. In the VL group, 85% of the time, they got it in every time. In the DL group, they were successful 70.8% of the time. This gives us a nice, single-digit, number needed to treat of 6.99.

It is important to note that the majority of these intubations, almost 70%, took place in the ED. 45% of the intubations took place because of altered mental status. Just 30% were in respiratory failure. That means that these patients don’t necessarily desaturate easily. I guess that means we should move on to the secondary outcomes.

Secondary Outcome of the DEVICE Trial

When it comes to the secondary outcomes of the DEVICE trial looking at VL vs. DL for intubation, there’s a great big not much happening here. Severe complications: no differences between the two groups. Desaturations below 80%? No difference. Hypotension? No difference. Vasopressor utilization? No difference. Cardiac arrests? No difference. The part that caught my eye is that in both groups around 21% of patients suffered a severe complication. 10% of patients desaturated to less than 80%. 12-13% of patients suffered either new or worsening hypotension which tells us more about intubation-related hypotension rather than the actual device used for intubation. When we obtain consent for airway procedures, these percentages need to be in the back of our minds.

Exploratory Outcomes looking at VL vs DL for Intubation

The authors also threw in some fun tidbits from the actual procedures that were not listed amongst the primary and secondary outcomes. Amongst those the median duration of intubation between DL and VL was about 8 seconds. That’s not too bad. There wasn’t as large a difference in the successful intubation on the first attempt without a severe complication. 17.3% of first attempts with DL failed due to an inadequate view of the vocal cords. Compare this to less than 4% in the VL group.

Why Should We Use VL instead of DL for Intubations?

I personally love subgroup analyses as we can tease out certain benefits or limitations of different therapies or tools. In this case, finding a single benefit to using DL over VL for intubation was impossible. The best one can say is that operators who had greater than 100 intubations did not have a difference in their outcomes that was statistically significant. Also, if fewer than 25% of your intubations were with DL and were asked to use VL, there was no difference in the success rate. To me, this means that using VL is extremely easy if you have the fancy handwork to be able to complete DL.

What’s Next?

If your shop does not have VL available for every intubation, they should spend the cash to obtain it. I personally use DL instead of VL for intubation every now and then simply to keep those skills. As a potential drawback, I am romanticizing about my training because moving forward using DL may not be emphasized as much. DL should still definitely be included in training programs. This should be a call, however, to those institutions and systems that do not have VL available. Here I include the potential for the EMS world to adapt to the technology should they not have it already. Long live DL. If you want to learn how to take care of the physiologically challenging airway, check out this article.

Should we pre-oxygenate our patients using HFNC or BVM? Check out THIS POST. Also, make sure to give @armyemdoc (Dr. Steve Schauer) a follow on Instagram and Twitter as he is an author on this paper.


Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz KP, Russell DW, Gaillard JP, Latimer AJ, Ghamande SA, Gibbs KW, Vonderhaar DJ, Whitson MR, Barnes CR, Walco JP, Douglas IS, Krishnamoorthy V, Dagan A, Bastman JJ, Lloyd BD, Gandotra S, Goranson JK, Mitchell SH, White HD, Palakshappa JA, Espinera A, Page DB, Joffe A, Hansen SJ, Hughes CG, George T, Herbert JT, Shapiro NI, Schauer SG, Long BJ, Imhoff B, Wang L, Rhoads JP, Womack KN, Janz DR, Self WH, Rice TW, Ginde AA, Casey JD, Semler MW; 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 Jun 16. doi: 10.1056/NEJMoa2301601. Epub ahead of print. PMID: 37326325.
Link to Article

Jabaley CS. Managing the Physiologically Difficult Airway in Critically Ill Adults. Crit Care. 2023 Mar 21;27(1):91. doi: 10.1186/s13054-023-04371-3. PMID: 36941620; PMCID: PMC10029275.
Link to Article

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