A taxonomy of key performance errors associated with hyperangulated video laryngoscopy for emergency intubation

Video laryngoscopy (VL) is now ubiquitous in emergency airway management. Hyperangulated video laryngoscopy (HAVL) differs from standard geometry VL (SGVL) in blade design, technique, and required microskills, yet the two are often regarded similarly. Despite widespread use, no comprehensive taxonomy of HAVL-specific performance errors exists.

We conducted an observational study of video-recorded endotracheal intubations (ETIs) performed in an urban academic emergency department (2020-2024). Fifty HAVL videos were first analyzed to derive 20 performance errors, followed by 100 additional recordings to confirm findings and assess incidence. Two independent emergency physicians evaluated each recording for performance errors. Interrater reliability and correlations among errors, procedure duration, and intubation success were assessed using Cohen's κ, Gwet's AC, and Pearson's correlation.

We identified 20 discrete performance errors associated with HAVL. All 100 recordings contained at least one performance error (pooled κ = 0.53, 95 % CI 0.48-0.58). The most common error was failure to engage the midline vallecula (56 %), and the least common was bougie delivery issues (1 %). Each additional performance error added approximately 3 s to intubation duration. Strong correlations were observed among several errors.

Performance errors during HAVL are common and interrelated. This novel taxonomy provides a framework for structured feedback, targeted training, and future investigation of HAVL technique and clinical outcomes.