Universal videolaryngoscopy: between current evidence and ethical imperatives

Editor, We sincerely thank Sorbello et al. for their thoughtful comments1 on our recently published Guidelines on Strategies for the Universal Implementation of Videolaryngoscopy (VL).2 Their interest in our work reflects the relevance of the ongoing debate on default VL use, and we welcome the opportunity to clarify methodological aspects and respond point by point. On the Delphi methodology and concerns of ‘circularity’ Sorbello et al. suggest a risk of circularity because the same group both drafted and voted on the statements. In fact, our process followed a multistep structure: drafting subgroups produced preliminary statements based on evidence synthesis, these were refined following an independent review by a steering group, and consensus was tested through structured Delphi rounds involving a multidisciplinary panel of 20 experts in anaesthesiology, intensive care, emergency medicine and prehospital care. This layered approach ensured both internal review and external scrutiny, thereby minimising bias. Guideline versus consensus statement We acknowledge the concern regarding terminology. However, the document meets the definition of a guideline; it is based on a systematic evidence review, framed within the GRADE methodology, and developed under the auspices of formally convened societies: the Airway Section of the Spanish Society of Anaesthesiology, Resuscitation, and Pain Therapy (SEDAR); the Spanish Society of Emergency Medicine (SEMES), the Latin American Federation of Emergency Medicine (FLAME) and an international group of experts. As in many areas of evolving practice, recommendations vary in strength: some, for example, routine VL versus direct laryngoscopy (DL), are supported by moderate-level evidence, while others rely on structured expert consensus where evidence is less definitive. This distinction is transparent in Table 2,2 which separates GRADE-based recommendations from consensus-based ones. Such duality does not undermine the document's status as a guideline, but instead reflects current evidence gaps that consensus must temporarily address, as in other airway guidelines. Further, we are hopeful that these guidelines will instigate further research in the areas where we have identified evidence gaps. On cost-effectiveness (statement 2) We agree that cost remains a key barrier. Our review highlighted studies showing that reductions in complications, intensive care unit (ICU) admissions and hospital length of stay can offset device costs. We also concur that life-cycle assessments and environmental analyses are needed, and explicitly identified sustainability as a research priority (Recommendation 11). Our position is not that VL is universally cheaper at present, but rather that, when viewed holistically, it has the potential to minimise costs in the long term, an interpretation shared by 85% of the experts. On ‘quality of care’ (statement 3) We defined quality of care using multidimensional indicators: first-attempt success, complication rates, operator stress, team performance and patient safety outcomes. These domains encompass both patient-centred and provider-centred measures. Meta-analyses consistently demonstrate superiority of VL over DL across most of these indicators.3 On setting-specific variability (statement 5) We agree that challenges of airway management differ across operating theatres, ICU, the emergency department (ED), and prehospital environments. Precisely for this reason, the multidisciplinary panel, comprising experts in anaesthesiology, critical care, emergency medicine and prehospital care, reached unanimous agreement (100% consensus) that universal availability of VL is essential, with training programmes to address the specific requirements of each clinical context. Furthermore, evidence from large-scale studies such as INTUBE,4 which demonstrated significantly higher complication rates in ICU and ED intubations, reinforces the recommendation that videolaryngoscopy should be adopted as the first-line technique in these high-risk environments. On simulation and training (statement 9) Our guideline did not intend to exclude manikin-based or in vivo-based technical training. Rather, it highlighted that high-fidelity simulation provides additional benefits such as safe rehearsal of crisis scenarios, improved team coordination and development of shared mental models. Evidence supporting its superiority over technical training alone is emerging, and we view these modalities as complementary rather than exclusive. On recommendations with ‘limited evidence’ We fully agree that further research is needed, which is why we included Recommendation 12: ‘Research is necessary to evaluate the universalisation process’. However, waiting for perfect evidence risks perpetuating a status quo that exposes patients to preventable complications with DL. Consensus-based recommendations offer pragmatic interim guidance while simultaneously stimulating further investigation. On the infographic and cognitive aid The cognitive aid (Fig. 2),2 derived from expert consensus, aligned with existing SEDAR/SEMES difficult airway algorithms,5,6 and refined through Delphi review. While some aspects remain debated (e.g. optimal use of stylets, VL+fibre-optic bronchoscopy combinations), the intent was to provide a structured decision-making framework, not a rigid algorithm. Its role is to encourage standardisation, training and research. In summary, we appreciate the constructive spirit of the comments of Sorbello et al. We respectfully submit that our guideline is methodologically rigorous, transparent about evidence limitations and justified in presenting consensus statements as interim recommendations. We believe that default VL is not only supported by the available evidence but also ethically imperative to reduce harm. Historically, airway practice has advanced through strong consensus in the face of incomplete evidence, and we view this as a continuity of that process. In anaesthesiology, as in many other medical disciplines, numerous guidelines have emerged; nonetheless, an initial framework is necessary to advance the field. We acknowledge that the present work does not represent the definitive word, but rather a foundation intended to stimulate further debate and systematic evaluation. Constructive criticism and additional evidence will be indispensable to refine, validate and update these recommendations over time. We also look forward to the outcomes of ongoing high-quality studies, which will further consolidate and reinforce the evidence base. Moreover, we welcome suggestions aimed at enhancing the implementation of VL and remain open to any recommendations that may contribute to making airway management safer and more effective.