Tracheal intubation performed using direct laryngoscopes has been the standard approach for almost a century. These simple devices consist of a handle and a blade with a light source. However, in the past two decades, video laryngoscopes have gained increasing popularity. Equipped with a camera near the blade's tip, video laryngoscopes offer improved visualization of the vocal cords. By displaying the images on a screen, clinicians can assess the proper placement of the endotracheal tube. Both direct and video laryngoscopes are utilized for intubating patients in the emergency department (ED) and intensive care unit (ICU). Unfortunately, failure to successfully intubate the trachea on the first attempt occurs in approximately 20-30% of cases in the ED and ICU. This high failure rate poses severe risks, including compromised oxygen levels in the blood, fluctuating blood pressure, cardiac arrest, and even death. Until recently, conclusive data comparing the efficacy of video laryngoscopes versus direct laryngoscopes in critically ill adults have been lacking. While video laryngoscopes are acknowledged for their improved visualization capabilities, their impact on the ease with which a tube is passed has remained uncertain. The available studies on this subject have been limited in scope, often conflicting, and unable to provide definitive evidence. Consequently, the adoption of video laryngoscopes has been slow.

Now, a study led by Vanderbilt University Medical Center (Nashville, TN, USA) comparing the two types of laryngoscopes used in tracheal intubation of critically ill patients has filled this crucial knowledge gap. The DEVICE (DirEct Versus VIdeo LaryngosCopE) trial has found that the use of a video laryngoscope increased successful intubation on the first attempt, compared to the use of a direct laryngoscope. The trial involved 1,417 patients from 17 emergency departments and ICUs in 11 hospitals around the country. The primary objective was to determine whether video laryngoscopes outperformed direct laryngoscopes in achieving successful intubation on the first attempt.

In this randomized trial, the results demonstrated a significant advantage for video laryngoscopes. The first-pass success rate was 85% in the video laryngoscope group, compared to 71% in the direct laryngoscope group, indicating an absolute increase of 14%. While the study also examined secondary outcomes such as complications like cardiac arrest, larger-scale trials are needed to confirm these findings definitively. Nonetheless, the substantial difference in first-attempt intubation success strongly supports the utilization of video laryngoscopes as the primary device for intubating critically ill adults in the ED and ICU. Moreover, the study indicated that video laryngoscopes may be particularly beneficial for less experienced clinicians. Further investigation is also needed to compare different types of video laryngoscopes, including those designed similarly to direct laryngoscopes and those with hyperangulated curved blades, to optimize their effectiveness.

“Some tracheal intubations are done by anesthesiologists who have intubated thousands of patients over their lifetime, but many in the ED and ICU are done by physicians who have less overall experience intubating,” said Matthew Semler, MD, MSc, assistant professor of Medicine in the Division of Allergy, Pulmonary and Critical Care Medicine, and co-senior author of the study. “The video laryngoscope appears to be especially helpful when the person performing the intubation is less experienced. It basically doubles the chances of putting a breathing tube in successfully on the first try, probably because of the ability to very clearly see the vocal cords.” 

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