DEVICE Trial

What was the research question (PICO)?

• Population: Critically ill adults undergoing tracheal intubation in an emergency department or ICU.

• Intervention: Video laryngoscopy for tracheal intubation.

• Comparison: Direct laryngoscopy for tracheal intubation.

• Outcome: The primary outcome was successful intubation on the first attempt, and the secondary outcome was the occurrence of severe complications during intubation.

How did they do it?

• The trial was a multicenter, randomized study conducted at 17 emergency departments and ICUs.

• Critically ill adults undergoing tracheal intubation were randomly assigned to either the video-laryngoscope group or the direct-laryngoscope group.

• The primary outcome was successful intubation on the first attempt, and the secondary outcome was the occurrence of severe complications during intubation.

• The trial was stopped for efficacy at the time of the single preplanned interim analysis.

• A total of 1417 patients were included in the final analysis, with 91.5% of them undergoing intubation performed by an emergency medicine resident or a critical care fellow.

What did they find?

• The use of a video laryngoscope resulted in a significantly higher incidence of successful intubation on the first attempt compared to direct laryngoscopy in critically ill adults undergoing tracheal intubation. Successful intubation occurred in 85.1% of patients in the video laryngoscopy group, compared to 70.8% in the direct layngoscopy group. Absolute risk difference between the two groups for successful intubation on the first attempt was 14.3 percentage points (95% CI, 9.9 to 18.7; P<0.001).

• The occurrence of severe complications during intubation was similar between the two groups.

Any limitations of the study?

• The study does not provide specific recommendations on which brand of video laryngoscope or blade shape leads to the best outcomes.

• The findings may not apply to operators with more experience, as 97% of the operators had performed fewer than 250 previous tracheal intubations.

• All the intubations occurred in an emergency department or ICU, limiting the generalization of the findings to the operating room.

• Patients, clinicians, and trial personnel were aware of the trial-group assignments, potentially introducing bias.

What does it mean?

• The use of video laryngoscopy for tracheal intubation resulted in a significantly higher incidence of successful intubation on the first attempt than direct laryngoscopy in critically ill adults in an emergency department or ICU.

• This finding has important clinical implications, as failure to intubate on the first attempt is associated with life-threatening complications.

• The study supports the increased use of video laryngoscopy in critical care settings, especially for less experienced operators who may benefit from improved laryngeal visualization.

• The trial's strengths include randomization, concealment of trial-group assignment, and data collection by an independent observer. However, it also has limitations that should be considered when interpreting the results.

• Overall, the findings of this trial suggest that video laryngoscopy can be a valuable tool for improving first-attempt intubation success in critically ill patients in the emergency department and ICU.