A clear glottic view does not guarantee an easy tube

Design

Prospective multicentre observational study with paired assessments

Population

5,302 videolaryngoscopic tracheal intubations across 44 hospitals

Primary outcome

Relationship between glottic view and tracheal tube delivery

Effect

Difficult or failed delivery in 6.3% with excellent view; 24.5% of poor-view cases still easy

Videolaryngoscopy is often documented by the laryngeal view alone, on the assumption that a good view means an easy intubation. This prospective study across 44 hospitals tested that assumption in 5,302 intubations, each scored independently on blade geometry, percentage of glottic opening, and tube delivery.

View and ease diverged in both directions. Among intubations with a poor view (glottic opening under 25%), a quarter were still easy. More striking, even with an excellent view (over 75% opening), 6.3% of first strategies were difficult or failed, and 10.2% were difficult or failed whenever the opening was 25% or more. Inter-rater agreement for the structured scheme was high.

The practical message is to stop equating a good view with a secured airway. Document what blade was used, what was seen, and what it took to pass the tube — and stay ready for a difficult delivery even when the larynx looks wide open.

• Prospective study of 5,302 videolaryngoscopic intubations across 44 hospitals.
• With a poor view (glottic opening under 25%), 24.5% of intubations were still easy.
• Even with an excellent view (over 75%), 6.3% of first strategies were difficult or failed.
• Record blade, view and tube delivery separately rather than view alone.
• Stay prepared for a difficult tube even when the glottis looks wide open.

Why it matters

It challenges the habit of documenting and judging videolaryngoscopy by laryngeal view alone, which can give false reassurance.

Don't overread it

This was observational; it describes the gap between view and tube delivery rather than testing whether the new documentation scheme improves outcomes.

The statistics, in plain English

That 6.3% of easy-view cases were still difficult shows the two measures are not interchangeable; the high inter-rater agreement means the structured scheme is reproducible enough to use in records.

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