Video vs direct laryngoscopy: what DEVICE showed
A 14-point absolute improvement in first-attempt success, stopped early for efficacy — and one population caveat that decides whether it applies to you.
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The DEVICE trial produced one of the largest effect sizes in recent airway literature and was stopped early because of it. It also has a population caveat that determines whether the result applies to you.
Key takeaways
- First-attempt success: 85.1% with video versus 70.8% with direct — an absolute difference of 14.3 percentage points.
- The trial was stopped early for efficacy at its single preplanned interim analysis.
- No difference in severe complications — 21.4% versus 20.9%.
- 91.5% of intubations were performed by trainees. This is the caveat that determines generalizability.
- Every subgroup favored video except experienced operators — those with more than 100 previous intubations, and those who had done most of their previous intubations with direct laryngoscopy.
- An earlier ICU trial found the opposite on safety, with more severe complications in the video group.
DEVICE
A pragmatic, multicenter, randomized trial at 17 emergency departments and intensive care units in the United States, enrolling 1,417 critically ill adults undergoing tracheal intubation, randomized 1:1 to a video or direct laryngoscope for the first attempt.1
| Outcome | Video | Direct | Difference |
|---|---|---|---|
| Successful first attempt | 600/705 (85.1%) | 504/712 (70.8%) | +14.3 pp (95% CI 9.9–18.7), p < 0.001 |
| Grade 1 laryngeal view | 76.3% | 44.7% | +31.6 pp (95% CI 26.7–36.6)2 |
| Severe complications | 151 (21.4%) | 149 (20.9%) | +0.5 pp (95% CI −3.9 to 4.9) |
| Esophageal intubation, dental injury, aspiration | Similar between groups | ||
Severe complications were defined as severe hypoxemia, severe hypotension, new or increased vasopressor use, cardiac arrest, or death occurring between induction and two minutes after intubation.1
The caveat that decides whether this applies to you
91.5% of the intubations were performed by an emergency medicine resident or a critical care fellow.1 DEVICE measured what happens when a relatively inexperienced operator intubates a critically ill patient outside the operating room.
The subgroup analysis makes this explicit: all subgroups favored video laryngoscopy except two — operators who had performed more than 100 previous intubations, and operators who had done fewer than a quarter of their previous intubations with a video laryngoscope.3 The benefit is largest where skill is lowest, which is exactly what you would expect from a device that removes the need for a direct line of sight.
The same pattern appears in neonates: a meta-analysis of nine randomized trials and 1,059 neonates found video laryngoscopy improved first-attempt success (RR 1.21, 95% CI 1.06–1.38), with subgroup analysis indicating the benefit was particularly for inexperienced clinicians.4
Why the earlier trials disagreed
DEVICE did not settle a question that was previously open in one direction — it settled a question where trials had genuinely pointed both ways.
| Trial | Setting | Finding |
|---|---|---|
| DEVICE (2023, n = 1,417) | 17 EDs and ICUs, mostly trainees | Video superior on first-attempt success; no difference in complications1 |
| MACMAN (2017, n = 371) | ICU, expert and non-expert operators | No difference in first-attempt success. More frequent severe life-threatening complications with video — 9.5% versus 2.8%5 |
| FELLOW (n = 150) | Single center, emergency intubation | No difference in first-attempt success3 |
| 2015 meta-analysis | Mixed | Video did not increase intubation success6 |
MACMAN is the one worth holding onto. It is smaller and older, but it found a safety signal in the opposite direction, in an ICU population including experienced operators. DEVICE did not replicate that — but nor did it study the same operators.
What this means in the operating room
DEVICE was conducted entirely outside the operating room, in critically ill patients, by trainees. Three things follow:
- For a trainee, or for an unfamiliar and difficult airway, the case for video is strong — a 14-point absolute improvement in first-attempt success and a 32-point improvement in laryngeal view is a large effect by any standard.
- For an experienced operator in an elective case, DEVICE does not answer the question. The two subgroups where the benefit disappeared are precisely that population.
- Better view does not automatically mean easier tube passage. The view improved by 31.6 points while first-attempt success improved by 14.3 — the gap is the well-recognized phenomenon of a good view with a difficult delivery, which is a hyperangulated-blade problem specifically.
The training question this raises. If video laryngoscopy produces better outcomes in the hands of inexperienced operators, and experience with direct laryngoscopy is what closes the gap, then adopting video universally removes the mechanism by which operators become experienced at direct laryngoscopy — which is the skill needed when the camera fails, the lens fogs, or blood obscures the view. DEVICE does not address this, and it is a real consideration in curriculum design rather than a reason to withhold the better device from a patient today.
Frequently asked questions
Is video laryngoscopy better than direct laryngoscopy?
For first-attempt success in critically ill patients intubated mostly by trainees, yes and substantially — 85.1% versus 70.8%, an absolute difference of 14.3 percentage points, in a trial stopped early for efficacy.1 Severe complications were no different. The benefit was smaller or absent in operators with more than 100 previous intubations.3
What did the DEVICE trial show?
That in 1,417 critically ill adults across 17 emergency departments and ICUs, a video laryngoscope produced successful first-attempt intubation in 85.1% versus 70.8% with a direct laryngoscope, and a grade 1 laryngeal view in 76.3% versus 44.7%.1,2 Severe complications occurred in 21.4% versus 20.9% — no difference. The trial was stopped early for efficacy.
Does DEVICE apply to elective operating room anesthesia?
Not directly. The trial was conducted outside the operating room in critically ill patients, and 91.5% of intubations were performed by an emergency medicine resident or critical care fellow.1 The subgroups where the benefit disappeared were operators with more than 100 previous intubations and those who had done most of their prior intubations with direct laryngoscopy.3
Has any trial found video laryngoscopy worse?
MACMAN, a 371-patient ICU trial published in 2017, found no difference in first-attempt success and reported more frequent severe life-threatening complications with video laryngoscopy — 9.5% versus 2.8%.5 It is smaller and older than DEVICE, and included experienced operators, but the safety signal ran in the opposite direction.
Should trainees still learn direct laryngoscopy?
DEVICE does not answer this. What it shows is that the benefit of video laryngoscopy is largest where experience is lowest and diminishes with operator experience.3 The implication for training — that universal video adoption removes the route by which direct laryngoscopy skill is acquired — is a curriculum question rather than a reason to choose a worse device for a patient in front of you.
Why did the laryngeal view improve more than the success rate?
The grade 1 view improved by 31.6 percentage points while first-attempt success improved by 14.3.1,2 That gap reflects a well-recognized phenomenon: seeing the cords is not the same as delivering the tube to them, particularly with hyperangulated blades where the tube must follow a curve the operator cannot control by line of sight.
References
- Prekker ME, Driver BE, Trent SA, et al; 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;389(5):418–429. doi:10.1056/NEJMoa2301601. PMID 37326325. ClinicalTrials.gov NCT05239195.
- Critical care alert: video versus direct laryngoscopy for tracheal intubation of critically ill adults — the DEVICE trial. EMRA. Reports the grade 1 view figures and absolute risk reduction.
- DEVICE trial summary. The Bottom Line. Reports the subgroup analyses, including the operators for whom the benefit did not hold, and the FELLOW comparison.
- Li X, Zhang X, Chen D, Yu C, Jiang X. Video vs direct laryngoscopy for tracheal intubation in neonates: a meta-analysis. Front Pediatr. 2025;13:1674255. doi:10.3389/fped.2025.1674255. Nine RCTs, 1,059 neonates.
- Collaborative VLS summary, The Bottom Line, citing MACMAN (JAMA 2017, n = 371): no difference in first-pass success, with severe life-threatening complications in 9.5% of the video group versus 2.8% of the direct group.
- Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022;4:CD011136.
- Further reading. DirEct versus VIdeo LaryngosCopE (DEVICE): protocol and statistical analysis plan. BMJ Open. 2023;13(1):e068978.
Disclaimer. Reference information for licensed clinicians and students. Not a medical device, and not a substitute for clinical judgment. DEVICE was conducted outside the operating room and mostly by trainees; generalizing it to experienced operators in elective cases goes beyond what it measured. Verify against your institutional protocol.
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