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A special article1 published in the British Journal of Anaesthesia from the DAS intubation guidelines working group, regarding the UK Difficult Airway Society (DAS) guidelines for management of unanticipated difficult intubation in adults, confirmed in relation to key features of Plan A that, ‘the role of videolaryngoscopy in difficult intubation is recognised’, and thatall anaesthetists should be skilled in the use of a videolaryngoscope.

The article also confirmed in a section discussing the choice of laryngoscope that, ‘
Videolaryngoscopes offer an improved view compared with conventional direct laryngoscopy and are now the first choice or default device for some anaesthetists. Regular practice is required to ensure that the improved view translates reliably into successful tracheal intubation
The article is open access and can be accessed using the following link:

The Flowchart for Management of unanticipated difficult tracheal intubation in adults includes VL in Plan A:

• Direct/video laryngoscopy (maximum 3+1 attempts).

The DAS guidelines can be viewed on the following link.

In the USA, the American Society of Anaesthesiologists Difficult Airway Algorithm in the ‘Practice Guidelines for Management of the Difficult Airway’2, published in the journal Anaesthesiology, recommends considering the relative merits and feasibility of basic management choices. This includes ‘Video-assisted laryngoscopy as an initial approach to intubation’. The guidelines also comment that meta-analyses of randomised controlled trials comparing video-assisted laryngoscopy with direct laryngoscopy report that for patients with predicted or simulated difficult airways video-assisted laryngoscopy provides:

• Improved laryngeal views
• A higher frequency of successful intubations
• A higher frequency of 1st attempt intubations



1. Frerk C, Mitchell V.S, McNarry A.F, Mendonca C, Bhagrath R, Patel A, O'Sullivan E.P, Moodall N.M, Ahmad I. Difficult AirwaySociety 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia 2020; 115: 827-48
2. Apfelbaum J.L, Hagberg C.A, Caplan R.A, Blitt C.D, Connis R.T, Nickinovich D.G, Benumof J.L, Berry F.A, Bode R.H, Cheney F.W, Guidry O.F, Ovassapian A. 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: 251-70

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