Videolaryngoscopy for all: A global proposal for safer airway management

Medical practice is defined by constant evolution—a pursuit of safer, more effective, and equitable care. In airway management, few innovations rival the transformative impact of videolaryngoscopy (VL). Once a backup tool for difficult airways, VL is increasingly recognised as the gold standard in laryngoscopy.[1,2]

This shift reflects decades of research, clinical experience, and consensus that direct laryngoscopy (DL) risks are no longer acceptable when safer alternatives exist.[3] The recent international consensus guidelines, developed collaboratively by the Spanish Society of Anaesthesiology (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Latin American Federation of Emergency Medicine (FLAME), alongside global airway experts, signal a turning point. These are not merely technical recommendations but a global call to action. VL must become the universal standard of care.

These guidelines affirm a transformative message in their inclusivity, scope, and evidence-based foundations: VL is no longer a privilege for well-resourced centres or select providers. It must become the standard of care for everyone, everywhere. The debate has passed; the task ahead is implementation. This is not merely a recommendation but a call to action for clinicians, institutions, educators, policymakers, and healthcare systems worldwide. Universal VL is not only possible; it is essential. And the time to act is now.

WHY UNIVERSALISE VIDEOLARYNGOSCOPY?

Tracheal intubation remains one of the most critical and high-risk procedures in medicine, performed across diverse settings: operating rooms, emergency departments, ICUs, and prehospital environments. Though widely taught, DL depends on aligning anatomical axes and the operator’s direct line-of-sight technique, which are inherently limited by patient anatomy.[4]

VL overcomes these limitations. It provides an enhanced, magnified glottic view without needing anatomical alignment. Numerous studies confirm VL’s superiority: higher first-pass success rates,[5,6,7,8,9,10] better glottic visualisation,[8,9,10,11] and fewer complications such as oesophageal intubation and airway trauma.[9,10,12] In critically ill patients, VL accelerates transitions to rescue strategies when seconds matter.[13] A recent meta-analysis found that first-pass success with VL can be 10%–15% higher than with DL in emergency settings—a difference that translates to thousands of avoided complications globally each year.[14]

Significantly, VL transforms airway management from a solo act into a shared task. With AI integration, VL could one day guide operators through real-time feedback. Already, Bluetooth-enabled devices allow many smartphones to function as shared viewing platforms, expanding access to team members in operating rooms and emergency settings. However, such shared visualisation typically incurs additional financial and infrastructural costs. Real-time shared visualisation allows entire teams to observe, assist, and learn. This shared mental model enhances communication, safety, and performance, especially in high-stakes situations.[15,16,17] For trainees, VL shortens the learning curve and improves retention; for experts, it reduces cognitive and physical strain.[18]

The COVID-19 pandemic further reinforced VL’s value by allowing a safer distance between the provider and the patient, reducing exposure to aerosolised particles, and protecting frontline workers.[19,20,21] VL’s benefits span patient and provider safety, an uncommon dual achievement. Systemically, VL offers value-based advantages: reduced complications lead to shorter ICU stays, fewer hospital days, and lower healthcare costs.[22,23] In an era of overburdened systems and cost-conscious care, VL stands at the intersection of safety, innovation, and economic rationale.

VL doesn’t just save lives, it improves the quality of survival. Less airway trauma means less long-term morbidity. Better first-pass success means less hypoxic injury.

BARRIERS TO ADOPTION. THE CHALLENGE OF INERTIA

Despite compelling evidence, VL remains underutilised. Barriers include equipment costs, training gaps, device variability, and institutional inertia. Among the most persistent challenges is cultural resistance:[24] experienced clinicians who remain confident in their DL skills may be reluctant to adopt newer tools. While understandable, this resistance is no longer defensible given the current evidence.

Cost is a major concern, particularly in low- and middle-income settings. Although VL can reduce complications and, thus, total costs, the initial investment in devices, maintenance, and training remains a challenge.[22] However, innovation offers hope: 3D-printed and smartphone-compatible VL devices are already demonstrating real-world feasibility and cost-effectiveness in resource-limited settings.

Healthcare’s history is full of once-controversial technologies that became indispensable—pulse oximetry, capnography, and ultrasound all faced resistance. VL belongs to that lineage. Resistance should be viewed not as a differing opinion but as a patient safety concern.

BREAKING THE CYCLE: INFRASTRUCTURE AND EDUCATION AS CATALYSTS

The new guidelines rightly emphasise that devices alone will not change practice. Adoption also requires infrastructure and robust education.

Successful implementation requires investment in training, simulation, protocols, and cognitive aids.[25,26] Standardisation of devices, availability of hyperangulated and standard blades across all care environments,[24] and sustainability considerations (especially for disposable devices) are essential to meaningful implementation.

Even in resource-limited settings, simulation-based education should be a core part of training, providing a safe and structured environment to introduce VL from the beginning. Early exposure at the undergraduate and graduate levels should be prioritised, framing VL as a technical tool and part of a patient safety culture. Embedding VL in training will normalise its use. Interprofessional education, supported by real-time screen-sharing, will enhance collaborative learning and allow immediate feedback from educators.

A GLOBAL IMPERATIVE, NOT A LUXURY

One of the strengths of the new guidelines is their international scope. By incorporating perspectives from low-, middle-, and high-income countries, they affirm that safe airway management should not be a function of geography. Access to VL must be seen as an issue of equity. Low-cost alternatives—including 3D-printed and mobile-enabled devices—are not theoretical; they are in use today and changing outcomes.[27,28]

Global health equity begins with equitable access to the tools of safety. In airway management, VL must become one of those tools.

FROM AVIATION TO AIRWAY: A LESSON IN SAFETY CULTURE

The guidelines make an important analogy: aviation. When safety-enhancing technologies become available in aviation, they are adopted rapidly. Pilots are trained, protocols are updated, and the tools become standard. This culture of immediate application has made aviation one of the safest industries globally.[29]

In healthcare, however, adopting proven safety tools can take years, even decades.[30] This delay is unacceptable when a patient’s life is at stake. VL should not be the exception. Like aviation, healthcare must treat evidence-based innovations as non-negotiable elements of practice.

Efforts such as those led by the World Federation of Societies of Anaesthesiologists (WFSA), which successfully promoted universal access to pulse oximeters, offer a model for VL dissemination.

Safety in aviation is never considered optional. Nor should it be in medicine.

A CALL TO EVERY SPECIALITY

The universalisation of VL is not the purview of anaesthesiology alone. Emergency physicians, intensivists, prehospital providers, paediatricians, and otolaryngologists perform airway management. VL must become a standard tool across disciplines. This is not a niche initiative; it is a multidisciplinary reform agenda.

Professional societies across specialities should endorse and operationalise VL guidelines—integrating them into training, credentialing, and quality metrics. The true success of this movement lies in its ability to transcend silos.

CONCLUSION: THE TIME IS NOW

Universal VL is not aspirational; it is achievable. The evidence is clear, the tools exist, and international consensus is strong. What remains is coordinated action: education, funding, infrastructure, and cultural change. As the guidelines emphasise, achieving global availability and acceptance of VL is a commitment to patient care safety, excellence, and equity. Let us act with urgency, unity, and determination never again to look away from the glottis, and no patient denied a safer airway.

Author contributions

Both authors contributed to conceptualisation, writing, and revising the manuscript.

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

The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.

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.

Funding Statement

None.