in the previous issue of critical care , mosier and colleagues   provide additional support to the growing body of evidence that using video laryngoscopy ( vl ) improves the first - pass and overall success rate of urgent / emergent tracheal intubation as well as lowering the incidence of esophageal intubation when compared with conventional macintosh ( curved blade ) direct laryngoscopy ( dl ) . they , like others , have found that video - assisted visualization affords a higher percentage of patients with a cormack - lehane i / ii view and assists the operator in achieving a higher percentage of glottis opening visualized , thus leading to an improved  ultimate success rate when compared with dl [ 2 - 4 ] . their detailed analysis of a complicated clinical situation - acutely ill , critical care patients who required urgent tracheal intubation in a medical intensive care unit setting by providers with a variable levels of experience and skill - is an area uncommonly reported in the literature but often represents the care provided when the anesthesia team is not the primary operator [ 5 - 7 ] . i applaud the consistent imperative toward the improvement of patient safety by this group ; each intubation was conducted under attending intensivist supervision . the shortcomings and limitations of dl , our  gold standard , in the ultra - high risk critically ill population who require urgent / emergent tracheal intubation are , again , on display . the congruent  line of sight and the path for tube insertion limit dl visualization and thus its success . vl typically provides an equal or improved view when compared with dl . however , laryngeal exposure is regarded as the simple portion of the vl process . intubation , even in skilled hands , may be more challenging or impossible , as success relies more heavily on the operator s skill and the patient s airway characteristics than the device itself . understanding that c - mac ( karl storz , tuttlingen , germany ) and glidescope ( verathon inc . , bothell , wa , usa ) technology possess divergent mechanical and optical complexities based on differing blade design should be highlighted here . combining them under a single vl category , as was done in this study , ignores these significant differences . therefore , vl deployment must be accompanied by diligent and continuous training , especially in light of the rotating house staff . simply placing vl equipment in - service without proper education proper pre - use instruction , hands - on demonstration , and simulation lab practice should be encouraged . first - attempt success is a worthy focus of research and a reasonable outcome measurement frequently used in comparative studies of different intubation devices . this is based on the understanding that complications are tempered when fewer intubation attempts are required . ultimate intubation success with the initial device regardless of the number of attempts ( 3 or more ) required by the supervised trainee . current airway management philosophy advocates a limit on laryngoscopic attempts and favors the rapid enlistment of an alternative management method in the hopes of limiting repetitive intubation attempts , thus reducing adverse airway and hemodynamic consequences . the authors did not report what alternative rescue methods were either made available or used to account for those not ultimately successful . i would opine that , in a general sense and especially in a teaching environment , more appropriately , early use of an alternative rescue device - that is , laryngeal mask airway , bougie , fiber optic bronchoscopy or vl  dl - is warranted [ 12 - 14 ] . the less experienced trainee should be taught that early deployment of a rescue device is smart as focusing one s efforts on  ultimate success with a single device may turn out to be insane. mosier s group raises an important question of whether vl technology can narrow the gap of success between experienced operators and novice trainees . i believe these authors and others are unraveling the evidence that this , indeed , is the case . vl is a significant leap forward toward improving patient safety , yet vl is only one piece of the airway puzzle and we must not become mesmerized by or solely reliant on its past successes . in the post-honeymoon period after vl deployment , drift away from adherence to airway fundamentals as their confidence mounts with their vl experience . an experienced airway manager realizes it is far easier to avoid trouble than to try to get out of it . in many cases , vl may compensate for sloppiness and  drift from airway fundamentals , but one should choose being lucky. employing management fundamentals such as proper positioning , that is , ramping for the obese , judicious administration of sedative - analgesics versus the rapid sequence approach , and maintaining spontaneous ventilation when appropriate and an awake technique when indicated for the ultra - high risk patient , is imperative . airway education should emphasize how to recognize difficult airway characteristics , should teach primary and rescue strategies , and should endorse synchronized and effective written and verbal communication between care providers and should recommend that the most experienced practitioners supervise the intervention , if not perform it , when appropriate . patient characteristics coupled with operator experience , judgment , and skill lead to or away from intubation success . as challenging as emergency airway management can be , we must do our best to teach those who will one day be responsible for it and equip them well . vl technology is a welcomed adjunct to the airway puzzle , yet continued vigilance toward its implementation into one s practice is required to maximize its usefulness regardless of the level of the operator s experience . paraphrasing einstein , knowledge is power and knowing the how and how not , the dos and donts , and when and when not to incorporate vl is just half the battle .
urgent and emergent airway management outside the operating room is fraught with complications due to the nature of its acuity , single or multiple system dysfunction or failure , and physiological disturbances . 
 these provide a challenge to the airway team and place the patient at grave risk for potentially life - threatening airway and hemodynamics - related consequences . 
 conventional laryngoscopy is rapidly being challenged by video - camera - assisted laryngoscopes that , in many cases , offer improved visualization of the airway . 
 successful intubation remains a lofty but attainable goal for airway specialists as well as the novice intubator . yet 
 to assume that airway management difficulties can be erased by incorporating a new device is optimistic but nave . 
 in regard to patient safety , the device is just one piece of the airway puzzle .