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DEVICE RCT – VL vs DL for Critically Ill Adults

July 7, 2023

Written by Sam Parnell

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Video laryngoscopy (VL) was associated with higher rates of first attempt intubation success compared to direct laryngoscopy (DL) for critically ill patients in the ICU and ED. Furthermore, use of VL was associated with better views of the glottis and was especially helpful for clinicians with less intubation experience.

VL vs DL for critically ill adults: The optimal DEVICE is clear (and likely available in HD)
Several recent studies have suggested that VL may improve glottic view and first-pass intubation success compared to DL. However, the data has not been clear, and the debate between VL and DL rages on.

Enter the DEVICE trial, a pragmatic, multicenter, randomized trial of 1,417 critically ill patients at 17 EDs and ICUs in the United States that compared VL to DL.

The primary outcome of successful first attempt intubation occurred in 600/705 patients (85.1%) in the VL group and 504/712 patients (70.8%) in the DL group (absolute risk difference, 14.3%; 95%CI, 9.9 to 18.7; P<0.001). More patients in the VL group had a Cormack–Lehane grade 1 view (76.3% vs 44.7%). Importantly, 91.5% of intubations were performed by Emergency Medicine residents or Critical Care fellows, and the majority of VL intubations (86.1%) were performed using a standard geometry blade. Of note, the trial was stopped early for efficacy during interim analysis.

Subgroup analyses (Figure 2 from the article below) showed that the improvement in first attempt success with VL was far more pronounced for novice operators (26.1% absolute difference for those with < 25 prior intubations) compared to more experienced operators (5.9% absolute difference for those with > 100 prior intubations). There was no significant difference in safety outcomes or severe complications between the two groups.

From cited article

How will this change my practice?
The evidence suggesting VL is superior to DL continues to mount, and this study is quite convincing that VL should be the first-line device to intubate critically ill adults. VL appears to be especially helpful for less experienced clinicians, likely due to better visualization of the glottis. DL is still an important skill and can be vital when technology fails or the camera is obscured. However, VL is my preferred modality for intubation, and this study makes me even more confident that VL (in conjunction with appropriate training and use of bougies/stylets) should be standard of care.

Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults [published online ahead of print, 2023 Jun 16]. N Engl J Med. 2023;10.1056/NEJMoa2301601. doi:10.1056/NEJMoa2301601

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