Still avoiding videolaryngoscopy in morbid obesity—A matter of tradition or missing evidence?

In airway management, few situations are as predictably difficult and risky as managing the airway of a morbidly obese patient. Difficult mask ventilation, reduced functional residual capacity, vital capacity, and chest wall compliance, as well as rapid desaturation with increased work of breathing and anatomically challenging airways, are well-documented risks.[1] The Fourth National Audit Project (NAP4) reported that 42% of patients who experienced major airway complications were classified as obese.[2] However, serious complications continue to occur, often due to inadequate preparation, failure to recognise high-risk situations, and insufficient rescue strategies, leading to severe outcomes such as brain injury, death, emergency surgical airway interventions, or intensive care unit admissions. Perhaps the most encouraging aspect of this challenge is that the associated risks are now well understood, and we increasingly possess effective tools and strategies to protect our patients against them.

Videolaryngoscopy has been proven to improve glottic visualisation and facilitate tracheal intubation in morbidly obese patients.[3,4] A meta-analysis incorporating 18 randomised controlled trials and involving a total of 1,594 patients with obesity found that videolaryngoscopy significantly enhances the likelihood of successful intubation on the first attempt when compared to direct laryngoscopy. The combined risk ratio was calculated as 0.42 (P = 0.0064). In 2021, the Canadian Airway Focus Group recommended videolaryngoscopy as the first-choice technique for all tracheal intubations.[5]

Despite robust evidence from meta-analyses, randomised controlled trials, and international guidelines recommending videolaryngoscopy as a first-line approach for airway management in morbidly obese patients, its routine use in this population remains suboptimal. In the INTUBE study, which focused on critically ill patients and identified obesity as one of the predictors of difficult airway management, first-pass intubation was successful in 85.4% of patients overall. The vast majority (82.8%) were intubated using direct laryngoscopy, while 17.2% were intubated using videolaryngoscopy.[6,7]

In a retrospective cohort study analysing data from 2,421 patients with severe obesity undergoing bariatric surgery, the first-pass success rate was found to be 95.4%.[8] However, a striking finding of this study was that videolaryngoscopes were used in only 3.5% of cases in this series.

And yet, despite all we know—and despite the clear advantages of videolaryngoscopy—many clinicians still opt for direct laryngoscopy as their first-line tool. Several factors contribute to this gap, such as clinician familiarity and the longstanding reliance on direct laryngoscopy, which continue to influence practice patterns, particularly among practitioners trained before the widespread adoption of videolaryngoscopes. Limited access to videolaryngoscopes, cost considerations, and a lack of standardised institutional protocols further hinder widespread implementation. Additionally, training deficiencies and inconsistent exposure to videolaryngoscopy during clinical education reduce operator confidence and delay skill acquisition. Misconceptions regarding the time and complexity of videolaryngoscope use, particularly in emergency settings, also persist despite evidence to the contrary. Furthermore, the risk of difficult airway in morbidly obese patients is sometimes underestimated, especially in the absence of overt anatomical challenges. Addressing these barriers requires a multifaceted approach, including policy-level interventions, structured training programs, and institutional commitment to integrating videolaryngoscopes into routine practice for high-risk groups such as morbidly obese patients. In this context, simple screening tools such as the STOP-BANG score may help identify patients at high risk for airway complications. The STOP-BANG questionnaire is an acronym-based tool that includes eight components: snoring, tiredness, observed apnoea, high blood pressure, body mass index (BMI) >35 kg/m², age >50 years, neck circumference >40 cm, and male gender. Notably, a STOP-BANG score of ≥5 is highly predictive of moderate-to-severe obstructive sleep apnoea and correlates with increased perioperative risk, including difficult mask ventilation, rapid desaturation, and failed intubation. Therefore, even in cases where clinicians perceive the airway as non-challenging, the presence of elevated STOP-BANG scores should prompt consideration of videolaryngoscopy as a first-line approach, given its superior glottic visualisation and higher first-pass success rate in high-risk patients.

Is this persistence rooted in habit, tradition, or are we mistaking outdated practice for some form of clinical bravery? Either way, the patient pays the price. The broad implementation of this technology faces several barriers, including inadequate training opportunities, concerns regarding the potential erosion of direct laryngoscopy skills, the financial burden associated with equipment acquisition and maintenance, as well as apprehensions about its environmental impact.[9]

Still, we continue to hear anecdotal defences: “I’ve always used direct,” or “It’s faster for me,” or worse, “I don’t need it.” But in whose interest are we making these choices? In critical care and anaesthesia, equipment should serve the patient, not the ego or habits of the operator. What makes this even more concerning is that we are not lacking the tools; we are lacking the will to change. The widespread adoption of videolaryngoscopes in our healthcare facilities was greatly accelerated by the COVID-19 pandemic.[10] Yet, change in practice remains inconsistent, often dependent on individual preference rather than clinical evidence.

In the context of airway management for morbidly obese patients, electing to forgo videolaryngoscope use based on the presumption of an uncomplicated course is neither ethically justifiable nor professionally responsible, considering the established risks commonly observed in this patient group. Such decisions, which prioritise convenience or uncertainty over patient safety, undermine the fundamental principle of “do no harm” in medical practice. Consequently, this issue extends beyond technical preference and directly pertains to patient safety.

One important question we should ask ourselves is this: why cannot we criticise clinicians when videolaryngoscopes are not routinely used in clinical practice or when direct laryngoscopy is preferred? One of the main reasons is the continued lack of robust data proving that videolaryngoscopes enhance patient safety. In a 2017 Cochrane review, the authors stated that videolaryngoscopes are likely to lower the incidence of intubation failure and increase the success rate of first-attempt intubations, while also providing enhanced visualisation of the glottis.[11] However, the authors were unable to make any claims about patient safety, because there was no evidence to suggest that the use of a videolaryngoscope decreases the occurrence of hypoxia or respiratory complications. That said, evidence supporting the patient safety benefits of videolaryngoscopy has been rapidly increasing in recent years. In another Cochrane systematic review published in 2022, data from 26,149 patients undergoing tracheal intubation were analysed. The study concluded that videolaryngoscopy is likely to offer a safer overall risk profile than direct laryngoscopy for adult patients.[12] This conclusion was supported by findings that Macintosh-style and channelled videolaryngoscopes are likely to decrease the occurrence of hypoxemic events, whereas hyperangulated videolaryngoscopes appear to lower the risk of oesophageal intubation.

As Pass et al.[13] mentioned in their editorial, the focus of the discussion should shift from questioning whether videolaryngoscopy is superior to direct laryngoscopy to exploring how its advantages can be consistently provided across all tracheal intubations and utilised effectively by all clinicians responsible for airway management. In patients with morbid obesity, standard rescue methods frequently prove ineffective, raising concerns about the decision to avoid using videolaryngoscopy.[14] Each additional laryngoscopy attempt increases the likelihood of airway oedema, potentially worsening the patient’s condition. In such scenarios, not utilising a videolaryngoscope—a device known to enhance safety and precision—may further compromise patient outcomes. Notably, the availability of second-generation supraglottic airway devices provides a critical safety net in cases of failed intubation, emphasising the importance of preparedness and adherence to difficult airway algorithms, rather than relying solely on conventional techniques.

In conclusion, to demonstrate improved patient safety, it is essential to generate and publish evidence showing that videolaryngoscopy not only offers a technical advantage but also leads to clinically meaningful and measurable improvements in patient outcomes. Achieving this requires strong interdisciplinary collaboration, as well as the robust collection and analysis of both controlled and observational data. Only when we can link patient-centred outcomes—such as reductions in hypoxemia incidence, aspiration rates, cardiopulmonary complications, intensive care unit length of stay, or mortality—to the use of videolaryngoscopes, can we confidently claim that videolaryngoscopy enhances patient safety. We believe that such evidence will pave the way for recommending its routine use. It is time for a shift—videolaryngoscopy must move from being an optional tool to becoming an essential component of standard airway management practice for all morbidly obese patients.

Author’s contribution

All authors contributed to planning, conceptualisation, writing and approving the manuscript.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

The AI tools have not been utilised in the manuscript, except for grammar corrections.

Declaration of use of permitted tools

Nil.

Presentation at conferences/CMEs and abstract publication

None.

Conflicts of interest

The authors declare that they have no conflicts of interest. Dr Rakesh Garg is the editor of this journal.

Funding Statement

None.