Video Versus Direct Laryngoscopy for Tracheal Intubation of Adults Who Are Critically Ill: What Does the DEVICE Trial Mean for Anesthesiologists?

CRITICALLY ILL PATIENTS frequently require airway management, including prompt endotracheal intubation. Compared to patients undergoing elective procedures in the operating room, patients in the intensive care unit (ICU) are more likely to have acute respiratory failure, gas exchange impairment, hemodynamic instability, decreased functional reserve, and difficult airway status.1De Jong A Jung B Jaber S Intubation in the ICU: We could improve our practice.Crit Care. 2014; 18: 209Crossref PubMed Scopus (50) Google Scholar,2Jaber S Amraoui J Lefrant JY et al.Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: A prospective, multiple-center study.Crit Care Med. 2006; 34: 2355-2361Crossref PubMed Scopus (491) Google Scholar For these reasons, endotracheal intubation in the ICU is associated with a higher complication rate, including failed intubation, hypoxia, and hemodynamic compromise.2Jaber S Amraoui J Lefrant JY et al.Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: A prospective, multiple-center study.Crit Care Med. 2006; 34: 2355-2361Crossref PubMed Scopus (491) Google Scholar Furthermore, those with cardiac pathology are particularly vulnerable to complications associated with unsuccessful first-time intubation,3Choudhury A Gupta N Magoon R et al.Airway management of the cardiac surgical patients: Current perspective.Ann Card Anaesth. 2017; 20: S26-S35Crossref PubMed Scopus (5) Google Scholar,4Patel AS Wang A Gonzalez-Ciccarelli L et al.The challenge of difficult airway management in the cardiac operating room.J Cardiothorac Vasc Anesth. 2022; 36: 1516-1518Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar and, interestingly, the incidence of difficult intubation may be higher in patients undergoing cardiac surgery.5Borde DP Futane SS Daunde V et al.Are cardiac surgical patients at increased risk of difficult intubation?.Indian J Anaesth. 2017; 61: 629-635Crossref PubMed Scopus (5) Google Scholar Recently, a well-designed, large multicenter randomized controlled trial (DEVICE) was published comparing first-pass success rate with video laryngoscopy (VL) versus direct laryngoscopy (DL) in patients in the ICU and emergency department (ED) among primarily nonanesthesiologists.6Prekker ME Driver BE Trent SA et al.Video versus direct laryngoscopy for tracheal intubation of critically ill adults.N Engl J Med. 2023; 389: 418-429Crossref PubMed Scopus (18) Google Scholar The authors reviewed the Prekker et al. DEVICE trial design, patient inclusion, and settings and discussed the outcome implications for the cardiac anesthesiologist and intensivist. Historically, DL has been the standard technique for securing the airway, but since the late 1990s, VL has emerged as an attractive alternative with hopes for improved patient outcomes.7Pieters BM Eindhoven GB Acott C et al.Pioneers of laryngoscopy: Indirect, direct and video laryngoscopy.Anaesth Intensive Care. 2015; 43: 4-11Crossref PubMed Google Scholar,8Apfelbaum JL Hagberg CA Caplan RA et al.Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway.Anesthesiology. 2013; 118: 251-270Crossref PubMed Scopus (1539) Google Scholar Due to the morbidity and mortality associated with intubation complications, several previous studies have attempted to address whether VL compared to DL lowers complication rates in patients who are critically ill.9Hansel J Rogers AM Lewis SR et al.Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.Cochrane Database Syst Rev. 2022; 4CD011136PubMed Google Scholar Results have been mixed10Lascarrou JB Boisrame-Helms J Bailly A et al.Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: A randomized clinical trial.JAMA. 2017; 317: 483-493Crossref PubMed Scopus (157) Google Scholar due to heterogeneous data, including various operator experience levels, patient populations, devices, techniques, and variable use of stylets. That said, more contemporary studies appear to favor VL over DL in patients who are critically ill.9Hansel J Rogers AM Lewis SR et al.Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.Cochrane Database Syst Rev. 2022; 4CD011136PubMed Google Scholar,11Vargas M Servillo G Buonanno P et al.Video vs. direct laryngoscopy for adult surgical and intensive care unit patients requiring tracheal intubation: A systematic review and meta-analysis of randomized controlled trials.Eur Rev Med Pharmacol Sci. 2021; 25: 7734-7749PubMed Google Scholar,12Brown 3rd, CA Kaji AH Fantegrossi A et al.Video laryngoscopy compared to augmented direct laryngoscopy in adult emergency department tracheal intubations: A National Emergency Airway Registry (NEAR) study.Acad Emerg Med. 2020; 27: 100-108Crossref PubMed Scopus (50) Google Scholar The DEVICE trial published in the New England Journal of Medicine elucidates the role of VL in modern ICU practice trends in a more controlled fashion. Based on the findings of DEVICE, it may be time for more widespread VL use among patients who are critically ill. Prekker et al. sought to determine whether using VL compared to DL increases the likelihood of successful tracheal intubation on the first attempt among patients who are critically ill.6Prekker ME Driver BE Trent SA et al.Video versus direct laryngoscopy for tracheal intubation of critically ill adults.N Engl J Med. 2023; 389: 418-429Crossref PubMed Scopus (18) Google Scholar Importantly, the secondary outcome included the evaluation of several severe complications between induction and 2 minutes after intubation. The study was performed in the United States among 10 ICUs and 7 EDs in 2022 as a pragmatic, multicenter, parallel cluster-randomized trial. Adults >18 years old who were neither prisoners nor pregnant and needed orotracheal intubation were included. Clinicians excluded patients based on whether they deemed the patient to have a contraindication for VL or DL, and if study procedures precluded immediate safe intubation. In total, 82 patients were excluded for these reasons (76 patients in the VL group and 6 patients in the DL group). The trial's design was such that randomization was assigned in a 1:1 ratio for patients undergoing intubation with VL versus DL in permutated blocks stratified by the trial site. The blinding of both the airway operators and outcome assessors was not possible, but the allocation remained concealed until after enrollment. The authors collected data from trained observers and the operator. Although a 1,920 patient sample size was deemed necessary to detect an absolute difference of 5% in successful intubation on the first attempt, enrollment was stopped early at the 1,000 patient interim analysis because of prespecified significant improvement in first-pass success rate with VL compared with DL. Of the 1,947 patients assessed for eligibility, 39 were excluded, with 1,420 enrolled (707 randomized to VL and 713 randomized to DL). Both arms were noted to be well-balanced regarding baseline characteristics, including age (54 v 55-year-olds), sex, and the Acute Physiology and Chronic Health Evaluation score (16 v 16). Intubations primarily occurred in the ED compared to the ICU (70% v 30%), with the primary indication for intubation being acute encephalopathy, acute respiratory failure, emergency procedures, and cardiac arrest. Most intubations were done by resident physicians (73% and 71%) and seldom performed by anesthesiologists (2.6% and 3.5%), with an equal median number of previous intubations performed by the operators in each arm (50% v 50%). There was heterogeneity among centers regarding the brand and shape of laryngoscope available and selected. A stylet or bougie was used routinely during the first attempt at intubation, and success was confirmed with waveform capnography or colorimetric end-tidal carbon dioxide detection. Only 14% of the VL group used a hyper-angulated blade. In terms of the primary outcome, successful intubation on the first attempt was higher in the VL group (85.1%) versus the DL group (70.8%), with an absolute risk difference of 14.3% (95% CI 9.9-18.7; p < 0.001). The authors also looked at severe complications between induction and 2 minutes after intubation as a secondary outcome, including desaturation below 80%, systolic blood pressure <65 mmHg, new or increased use of vasopressors, cardiac arrest, and death. There was no significant difference in severe complications in the VL group (21.4%) versus the DL group (20.9%) (absolute risk difference 0.5 [95% CI −3.9 to 4.9]). Successful intubation on the first attempt without any severe complications was achieved in 68.7% of patients in the VL group compared to 59% in the DL group (absolute risk difference, 9.7%; 95% CI, 4.5-14.8). Prekker et al. concluded that among patients who are critically ill who undergo endotracheal intubation in an ED or ICU performed nearly exclusively by nonanesthesiologists, the use of a VL resulted in a higher incidence of successful first-time intubation compared to the use of a DL (absolute risk difference 14.3%). This study, in addition to a growing body of recent works, suggested that VL increasingly should be considered as the primary airway securement device in patients who are critically ill, especially for inexperienced and nonanesthesiologist clinicians. The authors applaud the sleek study design and well-presented findings of Prekker et al. The substantial number of patients included and the prospective nature of the study is admirable. Limiting the study population to patients in the ED or ICU with intubation performed predominantly by a resident or fellow physician with similar intubation experience reduced confounding variables noted in prior studies. For locations in which intubation of patients who are critically ill is performed primarily by non-anesthesiologists, the data presented by Prekker et al. would support VL over DL for intubation success on the first attempt. Interestingly, despite a significant difference in first-attempt success, no significant difference was apparent in terms of complications (patient-centered outcomes) between VL and DL groups despite fewer first-attempt successes in the DL group. Due to the overall infrequent nature of intubation-related complications, the study was underpowered to detect a significant difference in complications between techniques. Despite the lack of significance detected, more esophageal intubations, aspiration events, and cardiac arrests resulted in death in the DL group. If VL increases safety during intubation, a compelling argument could be made for its use over DL in the above settings. Additionally, complications were assessed only during the 2 minutes after intubation, which may not have captured all intubation-associated events; for example, hemodynamic consequences of hypoxia may take longer to manifest depending on the extent of preoxygenation. It should be recognized that the current study is both an investigation of different laryngoscopy techniques and the performance of the bulk of those techniques by a specific cohort (ED and critical care residents, less often fellows). It is less clear how the results would differ if performed by anesthesiologists with extensive DL and VL experience. Furthermore, anesthesiologists and others who perform intubations are trained in the airway examination and subsequent selection of a particular intubation technique based on such information (ie, commonly selecting VL over DL for an airway that appears challenging on the examination). Patients in the DEVICE trial were randomized to the intubation technique; therefore, it is possible that a patient randomized to DL would have been otherwise intubated with VL if the airway technique were selected by the intubating individual based on the examination (considering the anticipated difficulty of laryngoscopy was described as “moderate” in 46.5% of patients who underwent DL). It is conceivable that VL and DL first attempt success rates would have been similar if the individual performing the intubation selected the laryngoscopy technique. Previously, many works have been published comparing VL versus DL for airway management among patients who are critically ill. Although not all previous studies agreed, recent systematic reviews and meta-analyses, in addition to the DEVICE trial, suggest that VL increases the success of first-pass intubation and may lead to improved patient safety, namely reduced hypoxia in adults who are critically ill.6Prekker ME Driver BE Trent SA et al.Video versus direct laryngoscopy for tracheal intubation of critically ill adults.N Engl J Med. 2023; 389: 418-429Crossref PubMed Scopus (18) Google Scholar,9Hansel J Rogers AM Lewis SR et al.Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation.Cochrane Database Syst Rev. 2022; 4CD011136PubMed Google Scholar,11Vargas M Servillo G Buonanno P et al.Video vs. direct laryngoscopy for adult surgical and intensive care unit patients requiring tracheal intubation: A systematic review and meta-analysis of randomized controlled trials.Eur Rev Med Pharmacol Sci. 2021; 25: 7734-7749PubMed Google Scholar It remains important, however, to remember that the skill of DL may be lifesaving in the setting of VL malfunction, lack of access to VL, or in the contaminated airway, and, as such, maintaining competence in DL deserves consideration. In teaching hospitals, VL may offer several advantages over DL. VL is associated with a higher first-pass success rate in both ED and ICU settings among novices,13Mackie S Moy F Kamona S et al.Effect of the introduction of C-MAC videolaryngoscopy on first-pass intubation success rates for emergency medicine registrars.Emerg Med Australas. 2020; 32: 25-32Crossref PubMed Scopus (4) Google Scholar, 14Lakticova V Koenig SJ Narasimhan M et al.Video laryngoscopy is associated with increased first pass success and decreased rate of esophageal intubations during urgent endotracheal intubation in a medical intensive care unit when compared to direct laryngoscopy.J Intensive Care Med. 2015; 30: 44-48Crossref PubMed Scopus (55) Google Scholar, 15Mosier JM Whitmore SP Bloom JW et al.Video laryngoscopy improves intubation success and reduces esophageal intubations compared to direct laryngoscopy in the medical intensive care unit.Crit Care. 2013; 17: R237Crossref PubMed Scopus (79) Google Scholar perhaps because VL is associated with improved laryngeal views.16Su YC Chen CC Lee YK et al.Comparison of video laryngoscopes with direct laryngoscopy for tracheal intubation: A meta-analysis of randomised trials.Eur J Anaesthesiol. 2011; 28: 788-795Crossref PubMed Scopus (95) Google Scholar, 17Hoshijima H Kuratani N Hirabayashi Y et al.Pentax Airway Scope vs Macintosh laryngoscope for tracheal intubation in adult patients: A systematic review and meta-analysis.Anaesthesia. 2014; 69: 911-918Crossref PubMed Scopus (40) Google Scholar, 18Griesdale DE Liu D McKinney J et al.Glidescope video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: A systematic review and meta-analysis.Can J Anaesth. 2012; 59: 41-52Crossref PubMed Scopus (276) Google Scholar Data also suggest that inexperienced operators may have a faster intubation time when VL is used.19Nalubola S Jin E Drugge ED et al.Video versus direct laryngoscopy in novice intubators: A systematic review and meta-analysis.Cureus. 2022; 14: e29578PubMed Google Scholar As VL allows multiple operators to view the glottis simultaneously, real-time coaching can occur, and early recognition of difficulty with airway securement can be identified readily by more experienced providers.20Low D Healy D Rasburn N The use of the BERCI DCI video laryngoscope for teaching novices direct laryngoscopy and tracheal intubation.Anaesthesia. 2008; 63: 195-201Crossref PubMed Scopus (94) Google Scholar,21Herbstreit F Fassbender P Haberl H et al.Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students.Anesth Analg. 2011; 113: 586-590Crossref PubMed Scopus (58) Google Scholar Although the American Society of Anesthesiologists’ difficult airway algorithm does not recommend VL over DL, it does mention the positive benefits the authors have already identified. Other guidelines suggest the use of VL over DL if the airway assessment is concerning for a difficult airway (French Society of Anesthesia and Intensive Care Medicine and UK Difficult Airway Society).22Quintard H l'Her E Pottecher J et al.Experts' guidelines of intubation and extubation of the ICU patient of French Society of Anaesthesia and Intensive Care Medicine (SFAR) and French-speaking Intensive Care Society (SRLF): In collaboration with the pediatric Association of French-speaking Anaesthetists and Intensivists (ADARPEF), French-speaking Group of Intensive Care and Paediatric emergencies (GFRUP) and Intensive Care physiotherapy society (SKR).Ann Intensive Care. 2019; 9: 13Crossref PubMed Scopus (70) Google Scholar,23Higgs A McGrath BA Goddard C et al.Guidelines for the management of tracheal intubation in critically ill adults.Br J Anaesth. 2018; 120: 323-352Abstract Full Text Full Text PDF PubMed Scopus (480) Google Scholar Although VL appears to provide multiple advantages over DL among inexperienced airway operators, these advantages seem to fade among experienced consultant anesthesiologists.24Sulser S Ubmann D Schlaepfer M et al.C-MAC videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department: A randomised clinical trial.Eur J Anaesthesiol. 2016; 33: 943-948Crossref PubMed Scopus (60) Google Scholar Furthermore, paradoxically, VL can create a false sense of security from its superior view of the larynx, whereas tracheal intubation remains challenging, especially in the hands of less-experienced operators.10Lascarrou JB Boisrame-Helms J Bailly A et al.Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: A randomized clinical trial.JAMA. 2017; 317: 483-493Crossref PubMed Scopus (157) Google Scholar Additionally, video optics are usually located at the tip of the blade, making the posterior oropharynx less easily visualized during VL, and this may lead to inadvertent pharyngeal tissue injury, longer intubation times, and the loss of an indirect view when confronted with a contaminated airway.25O'Gara B Brown S Talmor D Video laryngoscopy in the intensive care unit: Seeing is believing, but that does not mean it's true.JAMA. 2017; 317: 479-480Crossref PubMed Scopus (5) Google Scholar When performed by anesthesiologists or intensivists, the VL versus DL debate may be a moot point. However, in practices where the primary airway operators are less experienced or for nonanesthesia clinicians, the Prekker et al. DEVICE trial provided evidence that VL should be emphasized in adults who are critically ill.6Prekker ME Driver BE Trent SA et al.Video versus direct laryngoscopy for tracheal intubation of critically ill adults.N Engl J Med. 2023; 389: 418-429Crossref PubMed Scopus (18) Google Scholar Implementation strategies, as well as outcomes, should be reviewed closely.26Freund Y, Bloom B. Video laryngoscopy for intubation - time for a new paradigm? N Engl J Med;389:472-3.Google Scholar In the cardiac surgical suite specifically, besides using an anticipated difficult airway, VL may enhance teaching opportunities with learners and facilitate transesophageal echocardiogram probe placement.27Borde D Kumar C Jasapara A et al.Use of a video laryngoscope to reduce complications of transesophageal echocardiography probe insertion: A multicenter randomized study.J Cardiothorac Vasc Anesth. 2022; 36: 4289-4295Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Further publications comparing VL versus DL in various clinical scenarios are welcome.