A report published in the New England Journal of Medicine1 says video laryngoscopy is superior to direct laryngoscopy in successful first-pass tracheal intubation attempts across staff experience levels in the ICU and emergency department.

According to researchers, approximately 20 to 30% of tracheal intubations performed in the ED or ICU fail in the first attempt, which is associated with an increased risk of life-threatening complications such as hypoxemia, regurgitation/aspiration of gastric contents, bradycardia, and cardiac arrest.1 An estimated 80% of the ED/ICU intubations are performed with a direct laryngoscope, as well.1

To determine which method improves first-pass intubation success, a national group of researchers conducted the Direct versus Video Laryngoscope (DEVICE) trial across 17 US sites, including 7 emergency departments and 10 ICUs in 11 medical centers.1 The study randomized first attempt intubation with a video laryngoscope or direct laryngoscope in a 1:1 ratio amongst critically ill adults (age 18 years or older) who were undergoing orotracheal intubation.1

A total of 1,417 procedures were included in the study analysis: 705 VL vs 712 DL. Observers measured primary outcome (successful intubation on the first attempt) and secondary outcome (occurrence of severe complications between induction and 2 minutes after intubation).

According to the results, successful first-pass intubation occurred in 600 of the 705 patients (85.1%) in the video-laryngoscope group and in 504 of the 712 patients (70.8%) in the direct-laryngoscope group.1

Severe complications were nearly identical across both groups, occurring in 21.4% of VL group (151/705 patients) and 20.9% of the DL group (149/712 patients.1

The analysis also separated operators into three groups based on their intubation experience prior to the study:

  1. Less than 25 intubations performed
  2. 25-100 intubations performed
  3. More than 100 intubations.

Across all operator experience groups, video laryngoscopy outperformed direct laryngoscopy in successful first-pass intubations, according to the data. The greatest gap between first-pass success in VL vs DL was witnessed in the least experienced operator group, a difference of 27.1 percentage points (80.0 vs 59.3).1

Operators’ number of intubations
performed (prior to study)
Video laryngoscopy
first-pass success rate
Direct laryngoscopy
first-pass success rate
Less than 2580.0%53.9%
25 to 10085.9%73.7%
More than 10089.4%83.5%

Video laryngoscopy also performed as well or better than direct laryngoscopy in several other performance measures, including

  • Successful intubation on the first attempt without the occurrence of a severe complication,
  • Failure to intubate the trachea on the first attempt because of an inadequate view of the vocal cords
  • Failure to intubate the trachea on the first attempt because of an inability to insert a bougie or an endotracheal tube with a stylet
  • The median time interval between the initiation of laryngoscopy and intubation of the trachea
  • See the study for full results and comparisons here.

“Among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope,” the researchers concluded.1

Researchers believe these results could have “important clinical implications because failure to intubate on the first attempt is associated with life-threatening complications, and in current clinical care worldwide, most critically ill adults undergo intubation with a direct laryngoscope rather than a video laryngoscope.”1

Read the full study for more information.


  1. Prekker M, et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med 2023; 389:418-429. https://www.nejm.org/doi/full/10.1056/NEJMoa2301601

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