#18 Journal Club: VL versus DL

On this week’s installment of Critical Care Time, Nick & Cyrus tackle the recent multicenter, randomized DEVICE Trial, which compared direct vs video laryngoscopy in 17 American ICUs & EDs with the primary outcome of interest being successful intubation on first attempt. During this episode, we’ll take a deep dive into the paper, discuss other literature, and weigh-in ourselves based upon our own experiences and the data that’s available. Give it a listen and let us know what YOU think!

Quick Take Home Points:

  1. The DEVICE trial was a multicenter randomized trial comparing video laryngoscopy (VL) and direct laryngoscopy (DL) in critically ill adults, demonstrating a higher first pass success rate in the VL group (85.1%) compared to the DL group (70.8%), leading to the trial's early termination for benefit.

  2. VL was shown to provide better visualization during intubation, with a higher percentage of patients achieving a Cormack–Lehane grade 1 view (76.3% vs 44.7%) and a faster median intubation time (38 seconds vs 46 seconds) compared to DL, without a significant difference in complication rates.

  3. Subgroup analyses revealed that novice operators benefited more from using VL, with a significantly higher improvement in first attempt success compared to more experienced operators, suggesting VL's is particularly advantageous for those with less prior intubation experience. (Though even the most experienced operators benefited from VL.)

  4. The DEVICE trial's findings align with recent meta-analyses, reinforcing VL's superiority over DL in terms of airway visualization, time to intubation, and first pass success in critical care settings, advocating for VL as the standard care for critical care intubations.

  5. Nick & Cyrus’ conclusion: VL should be standard of care for critical care intubations.

Show Notes:

The DEVICE Trial

  • Design: DEVICE was a pragmatic, multicenter, randomized trial of 1,417 critically ill adults in 17 EDs and ICUs in the United States that randomized patients to either video laryngoscopy (VL) or direct laryngoscopy (DL).

    • 70% of intubations occurred in the ED, 30% in the ICU.

    • 95% of intubations were performed by either residents or fellows. 

    • The majority of VL intubations (86.1%) were performed using a standard geometry blade. About half the time they used a Bougie.

  • Primary endpoint:

    • First pass success: occurred in 85.1% (600/705 patients) in the VL group and 70.8% (504/712 patients) in the DL group.

      • That 14.3% difference was highly significant; absolute risk difference, 14.3%; 95%CI, 9.9 to 18.7; P<0.001.

      • The trial was stopped early for benefit.

  • Secondary endpoints:

    • Better visualization: More patients in the VL group had a Cormack–Lehane grade 1 view: 76.3% vs 44.7% with DL. There were also fewer grade 3 or 4 views: 3.7% with VL vs 21% with DL.

    • Faster intubation: The median duration of intubation, defined as the number of seconds between the start of laryngoscopy and intubation of the trachea, was 38 seconds in the VL group versus 46 seconds in the DL group.

    • Similar rates of complications were seen in both groups.

  • Subgroup Analyses:

    • The authors did several prespecified subgroup analyses (Figure 2). The most important and interesting looked at first pass success by prior airway experience. They found that the improvement in first attempt success with VL was larger for more novice operators.

      • Those with fewer than 25 prior intubations were 26.1% more likely to succeed on the first pass intubation. (NNT=4 to succeed on first intubation compared to DL)

      • For more experienced operators (with >100 prior intubations), the difference was only 5.9%. (NNT=17 to succeed on first intubation compared to DL)

Discussion

    • The DEVICE trial provides strong evidence that VL allows you to get a better view faster and be more likely to succeed in intubation on the first attempt. VL is clearly superior to DL for intubations performed in the ED and ICU. (Not applicable to elective intubations and those performed in the OR.)

      • VL should be standard of care for critical care intubations.

    • Traditionally, one criticism of VL is that “visualizing the vocal cords is easier but passing the tube is harder.” But importantly that’s not what this study found!

      • The operator reported that the reason for failure was inability to pass a bougie or ETT in 7% of VL intubations and 7.2% of DL intubations. So there was no difference in the rate of tube delivery problems.

Putting the DEVICE trial in context

    • Recent meta-analyses have found similar advantages to VL over DL in people with critical illness:

      • A 2023 meta-analysis of 15 studies that included nearly 2300 patients found significantly higher rates of airway visualization and time to intubation with VL compared to DL.

      • A 2024 meta-analysis of 8 studies that included over 5000 patients that demonstrated higher rates of first pass success with VL compared to DL in critical care intubations.


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