Evidence of benefit for one device may not translate to another device. Some VL systems apply hyperangulated blades with or without a channel to guide the tube, while other devices carry a standard geometry blade resembling a Macintosh blade. VL technology is diverse, so it is quite difficult to standardize assumptions about the class of devices as a whole. My bias favoring VL has existed for 2 decades, but I had previously acknowledged that the evidence was insufficient to support my claims. However, the time has come that every airway practitioner should be proficient with VL. I would be unwilling to serve as a consultant expert to testify against a colleague who selected DL as a primary approach because practitioners really should use the tools with which they are most proficient. In law, it is used to determine negligence and potential liability for a tort. Most commonly, it refers to the reasonable degree of care a person should provide to another person. “Standard of care” is a strong term because it carries legal implications. I am of the firm belief that VL should be the standard of care. The evidence clearly supports multiple clinical advantages in the operating room. Now, in 2022, we have moved beyond the learning curve of VL. Well-trained anesthesia practitioners were already quite proficient with DL, so it was difficult to demonstrate benefit, as this new technique came with a learning curve requiring experience for maximal efficacy. Early studies produced mixed results, as the devices were tested against our routine care of direct laryngoscopy (DL). Since then, much effort has been applied to determine the clinical efficacy of VL for intubation of adults and children both in the operating room and in emergency environments. VL has been clinically available for decades, but made major advancements in 2001, with the introduction of modern video screens, digital technology, and alternate blade designs. In this Pro-Con commentary article, we discuss whether videolaryngoscopy (VL) should be the standard of care for tracheal intubation, for which I will make the case. As airway management care increasingly transitions from DL to VL, providers should be aware of the benefits and risks to this practice change. However, it may still be challenging for institutions to secure purchase of VL for every intubating location, as well as back-up airway devices. While cost is a barrier to broad implementation of VL, those costs are normalizing. If VL is adapted as the standard of care, airway managers may no longer practice and retain competency in other airway techniques that may be required in the event of VL failure. While transition of care from direct laryngoscopy (DL) to VL may result in improved airway management outcomes, the reliance on VL may degrade other important clinical skills when they are needed most. In the case of failure, it is important to have back-up plans for airway management. But VL is not without complications and does not possess a 100% success rate. There is compelling evidence that VL improves first-pass success rates, reduces the risk of intubation failure and esophageal intubation, and has benefits in the difficult airway patient. In this debate, we explore not only the various benefits of VL, but also its limitations. Dr Aziz makes the case that VL should be the standard of care, while Dr Berkow follows with a challenge of that assertion. In this Pro-Con commentary article, we discuss whether videolaryngoscopy (VL) should be the standard of care for tracheal intubation.
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