Performance errors in Video Laryngoscopy

The required skills vary with laryngoscope geometry. Standard-geometry video laryngoscopy (SGVL) and hyperangulated video laryngoscopy (HAVL) have related but distinct performance-error taxonomies.

This page describes these recognised errors. A separate How to review a video laryngoscopy page applies the taxonomy during structured video analysis.

Importantly, a performance error does not necessarily result in failed intubation. Bryan et al found that 67% of successful HAVL intubations reviewed contained at least one error.

Standard-geometry video laryngoscopy (SGVL)

Standard-geometry video laryngoscopy (SGVL) formed the basis of the original published performance-error taxonomy. In 2023 Weingart et al published A taxonomy of key performance errors for emergency intubation. This included 13 discrete errors grouped into three procedural domains 1) Structure recognition during laryngoscope insertion, 2) Vallecular manipulation, and 3) Device delivery. This taxonomy provides a practical framework for recognising where a laryngoscopy attempt deviates from optimal technique and for giving specific, reproducible feedback.

Structure recognition (4)	Vallecular manipulation (5)	Device delivery (4)
Inadequate suction	Inadequate lifting force	Bougie delivery issue
Insertion off midline	Failure to engage midline of vallecula	Over-rotated insertion (Kovacs sign)
Overly deep insertion	Lost seating in vallecula	Tube delivery issue
Missed anatomical structure recognition	Not fully seated in vallecula	Premature withdrawal of camera
	Too much force in vallecula

Structure-recognition errors occur during blade insertion and orientation. Off-midline and overly deep insertion may progress to oesophageal visualisation, while missed anatomical structure recognition occurs when relevant airway landmarks are visible but not recognised by the operator. Vallecular-manipulation and device-delivery errors then reflect problems with blade positioning, glottic exposure, and passage of the bougie or tube.

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Hyperangulated video laryngoscopy (HAVL)

Hyperangulated video laryngoscopy (HAVL) provides an indirect view of the glottis and requires a different technical approach from SGVL. In 2025, Bryan published Hyperangulated video laryngoscopy in the emergency department and described blade-placement and tube-delivery problems during HAVL. In 2026, Bracey et al published A taxonomy of key performance errors associated with hyperangulated video laryngoscopy for emergency intubation. They formalised a 20-error HAVL taxonomy, incorporating shared, modified and technique-specific performance errors.

Structure recognition (6)	Vallecular manipulation (7)	Device delivery (7)
Blade-tip entry error*	Failure to engage midline vallecula	Bougie delivery issue†
Insertion off midline	Not fully seated in vallecula	Translation rather than rotation of ETT with rigid stylet*
Inadequate suctioning	Lost seating in vallecula	Anterior tracheal-ring hang-up without immediate release*
Overly deep insertion	Over-rotation blade insertion*	Glottic structure trauma*
Missed anatomical structure recognition†	Overriding the epiglottis*	Dislodged ETT during stylet removal*
Poor tongue control*	Too much force in the vallecula	Premature balloon inflation*
	Inadequate lifting force†	Premature withdrawal of camera

The HAVL taxonomy preserves the same broad procedural domains as SGVL but contains more errors (20 vs 13) and more technique-specific delivery problems. HAVL places greater emphasis on controlled blade entry, tongue management, spatial orientation, and the rotation and advancement of a rigid-styleted tube. The additional errors in the HAVL taxonomy reflect technical differences rather than simple relabelling of SGVL mistakes.

Recognising a performance error is only the first step. During video review, the clinician must also describe the sequence of events, identify any corrective manoeuvres, and decide whether a deviation reflects an error, a recovery strategy, or a necessary adaptation to anatomy. These principles are explored further in How to review a video laryngoscopy.

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References