2025/09/02 by Martin Petzoldt, Viktor A. Wünsch, Vera Köhl · 1 voice
Health Professions · Medicine · #Dysphagia Assessment and Management #Tracheal and airway disorders #Voice and Speech Disorders
paper · pdf · doi:10.1111/anae.16774
openalex created_date 2025/09/02 · openalex publication_date 2025/09/02 · openalex updated_date 2026/07/15
We thank Abraham-Thomas et al. [1] for emphasising the importance of consistent documentation of videolaryngoscopy findings for future airway management planning. The high diagnostic value and robust calibration of the Videolaryngoscopic Intubation and Difficult Airway Classification (VIDIAC) score [2] has been confirmed in several studies. Since its development, the VIDIAC score has undergone two large prospective external validation studies in children and adults [3, 4]. A flagging system based on documented VIDIAC scores has recently been prospectively evaluated; these standardised alerts showed a substantial positive impact on decision-making for future airway planning [5]. Nevertheless, we fully agree that further studies in different cohorts with varying equipment would still be desirable. It is worth noting that the Cormack and Lehane classification and percentage of glottic opening score, traditionally used to report the glottic view achieved by direct laryngoscopy, do not classify videolaryngoscopy accurately [2, 3, 6]. Various opinion-based classifications have been introduced, such as the Fremantle or Video Classification of Intubation (VCI) score, both of which lack empirical reasoning and proper validation. It may be relevant to mention that the development of diagnostic tools should follow established methodological protocols [7]. Physicians should only use validated scores, such as the VIDIAC, as using unvalidated classifications or those with known poor diagnostic performance might result in inappropriate treatment decisions, potentially leading to considerable over- or undertreatment [5, 7]. Validation refers to evaluating the predictive performance in a representative patient population [7]. The VIDIAC score includes six items related to blade–epiglottis interaction, glottic view and enlarged arytenoids that restrict the posterior laryngeal inlet (e.g. due to swelling, tumours, radiotherapy or inflammation) and thereby substantially impair tracheal tube placement [2]. These items are interrelated, making VIDIAC an adoptive score that covers the personal preferences and decisions of users [2, 4]. Abraham-Thomas et al. shared their impression that further predictors for tracheal tube delivery would be desirable. As far as we know, there is currently no evidence to support this assumption. It is an important strength of the VIDIAC score that it was derived from empirical evidence and not merely from eminent logic [2]. The VIDIAC components were identified as the most important items out of a large set of candidates through a rigorous data-driven approach. Although several predictors for tracheal tube delivery were candidates, only ‘enlarged arytenoids’ reached sufficient statistical relevance [2]; this could support upper airway obstructions as being the most critical underlying reason for difficult tracheal tube placement. Abraham-Thomas et al. argue that tracheal tube insertion can be especially challenging with hyperangulated blades and should be given particular emphasis when classifying videolaryngoscopy. However, additional attempts due to tracheal tube–laryngeal axis misalignment, commonly attributed to hyperangulated blades, might be affected by the proficiency of the user and improper adjunct use. The main purpose of a classification, however, is to reflect and preserve the personal risk profile of patients for the purpose of forward planning, not to monitor the individual learning curves of users. This does not alter the fact that devices, adjuncts and attempts should be documented descriptively in health records to delineate the procedural workflow. Accurate classification facilitates efficient clinical decision-making and is a hallmark of patient safety; it extends beyond a personal point of view and needs to be supported by robust scientific evidence. The VIDIAC is currently the only prospectively developed and validated videolaryngoscopy classification in adults and is supported by three diagnostic studies with over 1300 patients [2-4]. An additional study of 1201 patients confirmed its value for future airway management planning [5]. The VIDIAC score is used increasingly for consistent documentation in clinical information systems. Given this evidence, shouldn't VIDIAC be deemed the current clinical standard for videolaryngoscopy classification in health records?