'Can't intubate, can't oxygenate' scenarios are rare but are often poorly managed, with potentially disastrous consequences. In our opinion, all doctors should be able to create a surgical airway if necessary. More practically, at least all anaesthetists should have this ability. There should be a change in culture to one that encourages and facilitates the performance of a life-saving emergency surgical airway when required. In this regard, an understanding of the human factors that influence the decision to perform an emergency surgical airway is as important as technical skill. Standardisation of difficult airway equipment in areas where anaesthesia is performed is a step toward ensuring that an emergency surgical airway will be performed appropriately. Information on the incidence and clinical management of 'can't intubate, can't oxygenate' scenarios should be compiled through various sources, including national coronial inquest databases and anaesthetic critical incident reporting systems. A systematic approach to teaching and maintaining human factors in airway crisis management and emergency surgical airway skills to anaesthetic trainees and specialists should be developed: in our opinion participation should be mandatory. Importantly, the view that performing an emergency surgical airway is an admission of anaesthetist failure should be strongly countered.

Airway management is one of the core skills of the anaesthetist and various techniques of airway management have developed over many years. Initially, the only view of the glottis that could be obtained was an indirect view (indirect laryngoscopy). Late in the 19th century, a direct view of the glottis was obtained via various direct laryngoscopes. Currently, in the early 21st century, there has been a return to indirect laryngoscopy via videolaryngoscopy using a videolaryngoscope. The aim of this paper is to give a historical overview of the development of both direct and indirect laryngoscopy.

of first clinical applications 3-7 , its use in normal airways 8,9 , simulated difficult airways 10-13 and actual difficult airways 14,15 , leading on to trials comparing performance of one videolaryngoscope against another or against the conventional standard Macintosh blade 16 . The prolific data on the burgeoning number of devices can be bewildering to the user. The possible superiority of one VL device over another may not be evident when reviewing the literature, especially for novice videolaryngoscopists with limited experience. We have collated the experiences of several experienced videolaryngoscopists to help guide the assessment and use of these devices. This is not a formal study, therefore the conclusions and recommendations presented should be interpreted in that light. SUMMARYDue to the large number of videolaryngoscopes now available, it might be difficult for novice users to assess the various devices or use them optimally. We have collated the experiences of several airway management experts to assist in the assessment and optimal use of seven commonly used videolaryngoscopes. While all videolaryngoscopes have unique features, they can be broadly divided into those inserted via a midline approach over the tongue and those inserted laterally along the floor of the mouth. Videolaryngoscopes that are placed on the floor of the mouth displace the tongue antero-laterally and flatten the submandibular tissues. They generally require a conventional shaped bougie for tracheal intubation. Videolaryngoscopes that use the midline approach may have an in-built airway conduit for the tracheal tube or may require a 'J-shaped' stylet in the tracheal tube to negotiate the upper airway. This may cause difficulty when the tracheal tube is inserted through the glottis and the tip abuts the anterior wall of the subglottic space. Knowledge of the mechanism used by videolaryngoscopes to achieve laryngoscopy is essential for safe and successful tracheal intubation when using these devices.

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