Video vs direct laryngoscopy: what DEVICE showed

Name: Video vs Direct Laryngoscopy: What DEVICE Showed — Helix Anesthesia
Creator: Anastasia Jackson
Published: 2026-08-21

A 14-point absolute improvement in first-attempt success, stopped early for efficacy — and one population caveat that decides whether it applies to you.

Published August 21, 2026 · Last reviewed September 27, 2026 · Written by Anastasia Jackson, DNAP, CRNA

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The short answer

DEVICE found first-attempt intubation success of 85.1% with video versus 70.8% with direct, an absolute difference of 14.3 percentage points, and was stopped early for efficacy. Severe complications did not differ. The caveat that decides generalizability is that 91.5% of intubations were performed by trainees. Video was beneficial across every operator-experience subgroup; the benefit was simply largest where experience was lowest.

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.
Video was beneficial across every operator-experience subgroup, with the largest benefit where experience was lowest. In the most experienced operators (more than 100 previous intubations) the effect still favored video (+5.9 pp) but was no longer statistically significant (95% CI −4.1 to 16.0).¹
An earlier ICU trial raised a safety question in the other direction — but its prespecified comparison of life-threatening complications was negative, and the excess of severe complications with video came from a post hoc analysis.

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)^1,2
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

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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: video laryngoscopy was beneficial in every operator-experience subgroup, and a prespecified sensitivity analysis restricted to operators whose prior video and direct experience were comparable still significantly favored video (+13.5 pp, 95% CI 7.7–19.4). In the most experienced operators (more than 100 previous intubations) the point estimate continued to favor video (+5.9 pp) but lost statistical significance (95% CI −4.1 to 16.0).¹ 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 found video laryngoscopy improved first-attempt success (RR 1.31, 95% CI 1.20–1.44), and the benefit is larger in the neonatal ICU than in the operating room — consistent with a greater effect where operators are less experienced.^4,8

The experience gradient is not uniform across every setting, however. In the Cochrane meta-analysis the reduction in failed intubation was clear for expert intubators (RR 0.41, 95% CI 0.33–0.50) but did not reach significance for non-experts (RR 0.62, 95% CI 0.32–1.18), with no significant difference between the two subgroups.⁶ The novice-favoring gradient is strongest in critical-care intubation and less clear-cut across the broader, mostly-elective Cochrane dataset.

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, and none in life-threatening complications on the prespecified comparison — 13.3% video versus 9.5% direct, p = 0.25. A post hoc analysis of severe life-threatening complications favored direct laryngoscopy — 9.5% versus 2.8%, p = 0.01⁵
FELLOW (2016, n = 150)	Single-center medical ICU, intubation by critical care fellows	No difference in first-attempt success — 68.9% versus 65.8%, p = 0.68 — despite better glottic visualization with video⁷
Perioperative RCT (Schmid, 2026)	Operating room, anesthesia providers	Both video devices superior to direct — first-attempt success 78.2% direct versus 82.9% Macintosh-style video and 87.6% hyperangulated video⁹
Cochrane review (2022, 222 studies, 26,149 participants)	Mostly elective surgery; 21 studies outside the operating room	A Macintosh-style video laryngoscope probably reduces failed intubation — RR 0.41 (95% CI 0.26–0.65) — and may increase first-attempt success, RR 1.05 (95% CI 1.02–1.09)⁶

MACMAN is still worth holding onto, but for less than it is usually credited with. Its prespecified comparison of life-threatening complications was negative, and it ran numerically the other way — 13.3% with video versus 9.5% with direct, p = 0.25. The 9.5% versus 2.8% figure that gets quoted against video laryngoscopy comes from a post hoc analysis of the severe subset, and the trial report labels it as post hoc.⁵ That makes it a question worth carrying, not a result. What MACMAN shows without qualification is no first-attempt benefit in an ICU population that included experienced operators. DEVICE did not study the same operators — and found no difference in severe complications, 21.4% versus 20.9%.¹

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, and evidence-based reviews now recommend a video laryngoscope as the primary device for emergency intubation except for training or when it is unavailable.¹⁰
For an experienced operator in an elective case, DEVICE does not settle the question — the most experienced subgroup had a point estimate that still favored video but lost statistical significance, rather than a reversal of benefit.¹ A separate perioperative operating-room RCT (2026) does address this population directly: first-attempt success was 78.2% with direct versus 82.9% with a Macintosh-style video laryngoscope and 87.6% with a hyperangulated video laryngoscope, with both video devices superior to direct.⁹
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 largest in the least experienced operators and smallest — a point estimate that still favored video but lost statistical significance — in operators with more than 100 previous intubations.¹

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 In the most experienced operators the benefit lost statistical significance rather than reversing.¹ A 2026 perioperative operating-room RCT does address elective anesthesia and found both Macintosh-style and hyperangulated video laryngoscopes superior to direct laryngoscopy for first-attempt success.⁹

Has any trial found video laryngoscopy worse?

Not on a prespecified outcome. MACMAN, a 371-patient ICU trial published in 2017, found no difference in first-attempt success, and its prespecified comparison of life-threatening complications was negative — 13.3% with video versus 9.5% with direct, p = 0.25. The figure usually quoted against video laryngoscopy, 9.5% versus 2.8%, comes from a post hoc analysis of severe life-threatening complications, which the trial report labels as post hoc.⁵ It is a reason to keep asking the question rather than an established harm. DEVICE, almost four times larger, found severe complications in 21.4% versus 20.9%.¹

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. Reports first-attempt success, grade 1 view (76.3% vs 44.7%), severe complications, and the operator-experience subgroup and sensitivity analyses.
Critical care alert: video versus direct laryngoscopy for tracheal intubation of critically ill adults — the DEVICE trial. EMRA Critical Care Division, EM Resident, 3 August 2023. emresident.org/critical-care-alert-vl-dl-2023. Secondary summary of the grade 1 view figures and absolute risk reduction.
DEVICE trial summary. The Bottom Line. thebottomline.org.uk/summaries/device. Secondary summary of the subgroup analyses and the FELLOW comparison.
Xu W, Wang P, Wan J, et al. Comparison of video laryngoscopy and direct laryngoscopy for urgent intubation in newborn infants: a meta-analysis. Paediatr Respir Rev. 2025. Nine RCTs; first-attempt success RR 1.31 (95% CI 1.20–1.44).
Lascarrou JB, Boisramé-Helms J, Bailly A, et al; Clinical Research in Intensive Care and Sepsis (CRICS) Group. Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial (MACMAN). JAMA. 2017;317(5):483–493. doi:10.1001/jama.2016.20603. PMID 28118659. First-pass success 67.7% versus 70.3%, p = 0.60. Life-threatening complications, a prespecified secondary outcome: 24/180 (13.3%) with video versus 17/179 (9.5%) with direct, absolute difference 3.8% (95% CI −2.7 to 10.4), p = 0.25. In post hoc analysis, severe life-threatening complications 17/179 (9.5%) versus 5/179 (2.8%), absolute difference 6.7% (95% CI 1.8–11.6), p = 0.01.
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. doi:10.1002/14651858.CD011136.pub3. PMID 35373840. 222 studies, 26,149 participants. For Macintosh-style video laryngoscopes: failed intubation RR 0.41 (95% CI 0.26–0.65, moderate-certainty evidence), successful first attempt RR 1.05 (95% CI 1.02–1.09, low-certainty evidence). Intubator-experience subgroup for failed intubation: experts RR 0.41 (95% CI 0.33–0.50), non-experts RR 0.62 (95% CI 0.32–1.18), no significant subgroup difference. This is an update of the 2016 version of the same review (2016;11:CD011136, PMID 27844477), which searched to February 2015 and found no significant difference in the proportion of successful first attempts.
Janz DR, Semler MW, Lentz RJ, et al; Facilitating EndotracheaL intubation by Laryngoscopy technique and apneic Oxygenation Within the ICU (FELLOW) Investigators and the Pragmatic Critical Care Research Group. Randomized trial of video laryngoscopy for endotracheal intubation of critically ill adults. Crit Care Med. 2016;44(11):1980–1987. doi:10.1097/CCM.0000000000001841. PMID 27355526. 150 critically ill adults intubated by pulmonary and critical care fellows in the medical ICU of a single academic center; first-attempt success 68.9% with video (n = 74) versus 65.8% with direct (n = 76), p = 0.68, with better glottic visualization in the video group and no difference in time to intubation, lowest oxygen saturation, complications or in-hospital mortality.
Kuitunen I, Räsänen K, Huttunen TT. Video laryngoscopy in neonate and infant intubation — a systematic review and meta-analysis. Eur J Pediatr. 2024. Reports a larger first-attempt-success benefit for video laryngoscopy in the neonatal ICU than in the operating room.
Schmid B, Grüßer L, Müller L, et al. Conventional vs video-assisted laryngoscopy for perioperative endotracheal intubations: a randomized clinical trial. JAMA Netw Open. 2026. Perioperative operating-room RCT; first-attempt success 78.2% with direct versus 82.9% with a Macintosh-style video laryngoscope and 87.6% with a hyperangulated video laryngoscope, both video devices superior to direct.
DeMasi SC, Casey JD, Semler MW. Evidence-based emergency tracheal intubation. Am J Respir Crit Care Med. 2025. Recommends a video laryngoscope as the primary device for emergency intubation except for training or when it is unavailable.