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Randomized Controlled Trial
. 2025 May;167(5):1408-1415.
doi: 10.1016/j.chest.2024.12.031. Epub 2025 Jan 11.

Video vs Direct Laryngoscopy for Tracheal Intubation After Cardiac Arrest: A Secondary Analysis of the Direct vs Video Laryngoscope Trial

Amelia L Muhs  1 , Kevin P Seitz  2 , Edward T Qian  2 , Brant Imhoff  3 , Li Wang  3 , Matthew E Prekker  4 , Brian E Driver  5 , Stacy A Trent  6 , Daniel Resnick-Ault  6 , Steven G Schauer  6 , Adit A Ginde  6 , Derek W Russell  7 , Sheetal Gandotra  7 , David B Page  7 , John P Gaillard  8 , Lane M Smith  8 , Andrew J Latimer  9 , Steven H Mitchell  9 , Nicholas J Johnson  10 , Shekhar A Ghamande  11 , Heath D White  11 , Kevin W Gibbs  12 , Jessica A Palakshappa  12 , Derek J Vonderhaar  13 , David R Janz  14 , Micah R Whitson  15 , Christopher R Barnes  16 , Alon Dagan  17 , Ari Moskowitz  18 , Vijay Krishnamoorthy  19 , James T Herbert  19 , Michael D April  20 , Aaron M Joffe  21 , Jeremy P Walco  22 , Christopher G Hughes  22 , Kipp Shipley  22 , Amelia W Maiga  23 , Bradley D Lloyd  24 , Stephanie C DeMasi  24 , Wesley H Self  24 , Todd W Rice  2 , Matthew W Semler  2 , Jonathan D Casey  2 ; Pragmatic Critical Care Research Group
Affiliations
Randomized Controlled Trial

Video vs Direct Laryngoscopy for Tracheal Intubation After Cardiac Arrest: A Secondary Analysis of the Direct vs Video Laryngoscope Trial

Amelia L Muhs et al. Chest. 2025 May.

Abstract

Background: Airway management is a critical component of the care of patients experiencing cardiac arrest, but data from randomized trials on the use of video vs direct laryngoscopy for intubation in the setting of cardiac arrest are limited. Current American Heart Association guidelines recommend placement of an endotracheal tube either during CPR or shortly after return of spontaneous circulation, but do not provide guidance around intubation methods, including the choice of laryngoscope.

Research question: Does use of video laryngoscopy improve the incidence of successful intubation on the first attempt, compared with use of direct laryngoscopy, among adults undergoing tracheal intubation after experiencing cardiac arrest?

Study design and methods: This secondary analysis of the Direct vs Video Laryngoscope (DEVICE) trial compared video laryngoscopy vs direct laryngoscopy in the subgroup of patients who were intubated after cardiac arrest. The primary outcome was the incidence of successful intubation on the first attempt. Additional outcomes included the duration of laryngoscopy.

Results: Among the 1,417 patients in the DEVICE trial, 113 patients (7.9%) experienced cardiac arrest before intubation, of whom 48 patients were randomized to the video laryngoscopy group and 65 patients were randomized to the direct laryngoscopy group. Successful intubation on the first attempt occurred in 40 of 48 patients (83.3%) in the video laryngoscopy group and in 42 of 65 patients (64.6%) in the direct laryngoscopy group (absolute risk difference, 18.7 percentage points; 95% CI, 1.2-36.2 percentage points; P = .03). The mean duration of laryngoscopy was 48.0 seconds (SD, 37.3 seconds) in the video laryngoscope group and 98.0 seconds (SD, 122.4 seconds) in the direct laryngoscopy group (mean difference, -50.0 seconds; 95% CI, -86.8 to -13.3 seconds; P = .004).

Interpretation: Among adults undergoing tracheal intubation after experiencing cardiac arrest, use of video laryngoscopy was associated with increased incidence of successful intubation on the first attempt and shortened duration of laryngoscopy, compared with use of direct laryngoscopy.

Keywords: cardiac arrest; direct laryngoscopy; intubation; video laryngoscopy.

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Conflict of interest statement

Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: N. J. J. served on the scientific advisory board for Neuroptics, Inc., as well as on guidelines committees for the International Liaison Committee on Resuscitation and the American Heart Association. S. H. M. received travel support from SharpMed. M. W. S. served as a member of an advisory board for Baxter International, Inc. None declared (A. L. M., K. P. S., E. T. Q., B. I., L. W., M. E. P., B. E. D., S. A. T., D. R.-A., S. G. S., A. A. G., D. W. R., S. G., D. B. P., J. P. G., L. M. S., A. J. L., S. A. G., H. D. W., K. W. G., J. A. P., D. J. V., D. R. J., M. R. W., C. R. B., A. D., A. M., V. K., J. T. H., M. D. A., A. M. J., J. P. W., C. G. H., K. S., A. W. M., B. D. L., S. C. D., W. H. S., T. W. R., J. D. C.).

Figures

Figure 1
Figure 1
Graph showing the cumulative incidence of successful intubation on the first attempt and 95% CIs (shaded areas) among patients with cardiac arrest in each trial group relative to the time since the initial insertion of a laryngoscope blade into the mouth. Displayed percentages and P values are from the primary analysis, rather than the cumulative incidence model. Successful intubation on the first attempt occurred in 40 of 48 patients (83.3%) in the video laryngoscope group and in 42 of 65 patients (64.6%) in the direct laryngoscope group (absolute risk difference, 18.7 percentage points; 95% CI, 1.2-36.2 percentage points; P = .03, χ2 test).
Supplementary Figure 1
Supplementary Figure 1
See this image and copyright information in PMC

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