The VIDIAC score: a point of view, but does it reflect the whole picture?

We read with interest the Science Letter by Köhl et al. [1], which reports a prospective external validation of the videolaryngoscopic intubation and difficult airway classification (VIDIAC) score [2] using both Macintosh and hyperangulated videolaryngoscope blades. The authors are to be commended for extending the evaluation of their difficult airway scoring system to different blade geometries, an important consideration in laryngoscopy. We suggest, however, that further work may be needed before the VIDIAC score can be considered universally applicable in clinical practice and research. We note that the original VIDIAC study intended to represent anaesthetists with varying levels of experience, capturing the variability inherent in daily clinical practice [2]. In contrast, the BLADESHAPE study acknowledges that hyperangulated videolaryngoscopy is a more complex skill, with superior glottic visualisation translating into shorter tracheal intubation times only in experienced hands [3]. While the VIDIAC score effectively captures predictors related to glottic view and epiglottic manipulation, it does not explicitly include predictors for tracheal tube delivery. This consideration is particularly relevant to hyperangulated videolaryngoscope blades, which, despite improved glottic views, have well-documented challenges associated with tracheal tube insertion [4]. With this in mind, the performance of the VIDIAC score for hyperangulated videolaryngoscopy in less experienced hands remains an important area for future research. We also note that both the development and validation studies were conducted exclusively using the Storz C-MAC videolaryngoscope (Karl Storz SE & Co KG, Tuttlingen, Germany). It is not yet clear whether the findings apply to other videolaryngoscope manufacturers or blade designs, where subtle differences in geometry, blade angle and ergonomics may affect performance and limit generalisability of the score [4]. Similarly, validation in more varied patient populations, surgical contexts and emergency settings would strengthen confidence in the broader applicability of the score. We agree wholeheartedly with the authors that consistent documentation of videolaryngoscopy findings is pivotal for airway planning. To be truly universal, a videolaryngoscopy scoring system should, ideally, not only predict difficulty but also enable standardised documentation and provide actionable guidance to clinicians to support safe future airway management across diverse settings. The VIDIAC score is determined from the current tracheal intubation experience and does not provide a prospective prediction of difficulty. Essentially, it indicates that when tracheal intubation is challenging, subsequent attempts are also likely to be difficult. Retrospective flagging can assist in categorising levels of difficulty and standardising alerts; however, it may not contribute to forward planning or documentation of the procedures used during successful tracheal intubation. Establishing consistent, standardised language and documentation for videolaryngoscopy remains essential to informing future airway management strategies and improving patient care.