The Difficult Airway Society published its 2025 tracheal intubation guidelines in the British Journal of Anaesthesia in November 2025. One recommendation changes the standard of care for every anaesthesia department: video laryngoscopy is now the first-line device for adult tracheal intubation. It is no longer a backup tool for difficult cases. This guide explains what the DAS 2025 guidelines say, why the evidence is definitive, and what your department must do next.
What the DAS 2025 guidelines say about video laryngoscopy
The DAS 2025 guidelines make a direct, unambiguous recommendation for Plan A intubation. They state that a videolaryngoscope should be used first line to facilitate tracheal intubation whenever possible (Ahmad I et al., Br J Anaesth, 2026;136:283–307). The evidence behind this is clear: video laryngoscopes raise first-attempt success rates, reduce hypoxaemia during intubation, and cut the risk of oesophageal intubation.
The guidelines draw on 1,241 papers reviewed over three years. A three-round Delphi consensus process produced 65 recommendations. This is not a rushed update based on one trial. It reflects years of accumulated, consistent evidence.
The editorial companion to the guidelines puts it plainly: equipoise between video laryngoscopy and direct laryngoscopy no longer exists. Across patient groups and provider levels, videolaryngoscopy outperforms direct laryngoscopy.
How DAS 2025 differs from DAS 2015
The 2015 DAS guidelines arrived before video laryngoscopy was widely available. They acknowledged its role in difficult airways but did not make it the default for Plan A. The whole framework centred on managing failure: Plans A, B, C, and D formed an escalating rescue sequence.
The 2025 update keeps the same A through D structure. Plan A covers tracheal intubation, plan B covers supraglottic airway devices, plan C covers facemask ventilation, and Plan D covers emergency front-of-neck access using the scalpel-bougie-tube technique. The structure stayed the same. The philosophy did not.
DAS 2025 shifts the focus entirely. The goal is now to engineer success on the first attempt, not to manage the fallout from failure. Three specific changes drive this. First, the guidelines call for earlier and more complete neuromuscular blockade to optimise intubation conditions. Second, peroxygenation before every attempt is now a baseline requirement. The guidelines recommend high-flow nasal oxygen to extend safe apnoea time. Third, human factors now carry explicit weight. Situational awareness, role assignment, briefings, and structured debriefing are formal requirements, not suggestions.
Why the evidence is now definitive
Some departments held on to direct laryngoscopy for routine cases. Their argument was that video laryngoscopy added cost and training load without enough clinical gain. The 2025 DAS guidelines end that argument.
The Cochrane meta-analysis by Hansel et al. (Cochrane Database Syst Rev, 2022;4:CD011136) analysed more than 200 randomised controlled trials covering over 26,000 patients. Video laryngoscopes reduced failed intubation rates and raised first-attempt success across all patient groups and operator experience levels. The findings held regardless of the setting.
The 2024 JAMA cluster randomised trial by Ruetzler et al. covered 8,429 procedures across 16 operating rooms. Hyperangulated video laryngoscopy cut the share of patients needing more than one intubation attempt from 7.6% to 1.7%. That reduction means fewer complications, less airway trauma, and shorter ICU stays.
A 2025 narrative review in Anaesthesia by Kelly et al. examined default video laryngoscopy rollout across five UK NHS hospitals. Departments moved to video laryngoscopy as their routine first choice. Direct laryngoscopy training outcomes also improved. The shared screen gave whole teams real-time situational awareness during difficult airway events. Communication and teamwork got better, not worse.
Three findings stand out from this evidence base. Video laryngoscopy does not slow down routine cases. It does not erode direct laryngoscopy skills when rolled out correctly. And its benefits reach all operator levels, not just trainees.
What “first line” means operationally for your department
The clinical debate is settled. The harder question is what first-line adoption actually demands from your department. Most commentary on the DAS 2025 guidelines stops at the clinical summary. It should go further.
Equipment availability
First-line video laryngoscopy means every anaesthetic room needs a device. A video laryngoscope sitting in a difficult airway trolley down the corridor does not meet the standard. The DAS 2025 guidelines note that local provision should reflect widespread availability and regular use. The phrase “whenever possible” refers to equipment access, not clinical preference.
A department running 10 to 15 cases per list across multiple theatres needs to rethink its unit count. Two or three devices for rescue intubation is not enough. The right starting point is an audit: count your available units, map them against your peak simultaneous caseload, and calculate the gap. A universal monitor platform that accepts both reusable and disposable blades across departments cuts capital expenditure while keeping the device where it needs to be.
For more detail on equipment options, see our guide on reusable vs disposable vs hybrid video laryngoscopes.
Blade selection under the DAS 2025 framework
The DAS 2025 guidelines take a clear position on blade choice: no strong evidence supports one design over another. Both hyperangulated and Macintosh-profile video laryngoscopes are endorsed. Each requires a different technique. Departments need to stock both, or run a monitor platform that accommodates both on a single unit.
This is a practical position, not a gap in the evidence. Departments vary in case mix, clinician training, and equipment history. The guidelines give departments room to match blade choice to their specific situation. What they do not allow is using that flexibility as a reason to delay adoption.
For a clinical breakdown of when hyperangulated blades outperform Macintosh-profile designs, see our analysis of hyperangulated vs Macintosh blade selection in difficult airways.
Training requirements
The DAS 2025 guidelines link first-line adoption directly to training and regular use. A device in the anaesthetic room that clinicians rarely use adds cost without benefit. Your training programme needs to cover both Macintosh-profile and hyperangulated technique for every grade level.
The Kelly et al. review found something worth noting: video laryngoscopy improved direct laryngoscopy training. When novice anaesthetists learn direct laryngoscopy using a Macintosh-profile video laryngoscope, the trainer can point out structures in real time on the shared screen. That visibility improves skill acquisition. The fear that video laryngoscopy degrades direct technique does not hold when departments implement it correctly.
The guidelines also assign responsibility to institutions, not just individual clinicians. Simulation, debriefing, and airway governance are now organisational duties. Departments should run regular simulation scenarios for unanticipated difficult intubation and build structured post-event debriefs into standard practice.
How to use DAS 2025 as a procurement justification
Clinical leads who need budget for additional units now have the strongest procurement argument available. A first-line recommendation from the Difficult Airway Society, backed by a Cochrane review of more than 200 randomised controlled trials, meets the evidence threshold most hospital value analysis frameworks require.
Build your procurement submission around four points. First, cite the clinical evidence directly: the DAS 2025 guidelines, the Cochrane meta-analysis, and the 2024 JAMA trial. Second, make the patient safety case: each intubation attempt after the first raises the risk of airway trauma, hypoxaemia, and serious complications. Video laryngoscopy cuts multi-attempt rates. Third, raise the compliance issue: a department that does not adopt first-line video laryngoscopy now sits outside the current guideline standard. That carries medicolegal weight. Fourth, present the cost argument: the per-procedure cost of video laryngoscopy, particularly with a reusable or hybrid system, is small compared with the cost of a failed or prolonged intubation episode.
For help structuring a total cost of ownership analysis, see our hospital buying guide for procurement teams. It applies equally to NHS trust settings.
DAS 2025 in global context: how it aligns with ASA and CAFG
DAS 2025 is a UK document. Its reach extends further than the NHS. Departments in North America should understand how it sits alongside the two other major guidelines currently in force.
The ASA 2022 Practice Guidelines (Apfelbaum JL et al., Anesthesiology, 2022;136(1):31–81) recommend video-assisted laryngoscopy as an initial approach and list it among alternative intubation options for both anticipated and unanticipated difficult airways. The ASA does not yet use first-line language. However, the direction is consistent with DAS 2025. The 2024 JAMA trial and the Cochrane data will likely shape the next ASA revision.
The Canadian Airway Focus Group endorses video laryngoscopy for difficult airway management. Canadian emergency departments, ICUs, and operating theatres are moving in the same direction. The trajectory matches DAS.
In the UK, DAS 2025 sets the current standard. In North America, the ASA 2022 guidelines and the evidence base point the same way. The clinical question has an answer. What remains are the operational and procurement decisions.
What your department should do now
The following six steps give departments a clear path from video laryngoscopy as a rescue device to video laryngoscopy as the first-line standard.
Step 1: Audit your current inventory. Count available video laryngoscope units against your peak simultaneous caseload. Include all anaesthetic locations: operating theatres, emergency theatres, ICU, and any area where intubation may happen.
Step 2: Calculate your equipment gap. Determine how many additional units you need. Assess whether a universal monitor platform that accepts multiple blade types can meet your availability requirements at a lower capital cost.
Step 3: Check your blade coverage. The DAS 2025 guidelines do not mandate a specific blade geometry. Confirm your department stocks both Macintosh-profile and hyperangulated blades. Confirm clinicians hold technique training for each.
Step 4: Update your airway algorithm. Revise departmental airway algorithms and theatre checklists. Plan A is now video laryngoscopy. Align your posted materials with the DAS 2025 A through D framework.
Step 5: Build your training programme. Map competency requirements across all grade levels. Schedule simulation sessions for unanticipated difficult intubation scenarios. Establish structured debriefs after real airway events.
Step 6: Prepare your procurement submission. Anchor it to the DAS 2025 guidelines. Build the business case around patient safety outcomes, guideline compliance, and total cost of ownership. Bring anaesthetic clinical leads in as internal champions.
Astra-vue offers video laryngoscope systems in reusable, single-use, and hybrid configurations on a single universal monitor platform. The design supports first-line adoption across multiple departments without duplicating capital expenditure. To understand why imaging quality matters in this transition, read why imaging quality matters in intubation success. For product information and UK availability, contact our team or explore the full product line.
Frequently asked questions about the DAS 2025 guidelines and video laryngoscopy
What did the DAS 2025 guidelines change about video laryngoscopy?
The DAS 2025 guidelines moved video laryngoscopy from rescue tool to first-line device for Plan A tracheal intubation in adults. Previous DAS guidance acknowledged its role in difficult airway management but did not make it the default. The 2025 update reflects evidence from large randomised trials and meta-analyses showing consistent superiority over direct laryngoscopy across patients, settings, and operators.
Does DAS 2025 recommend a specific blade type?
No. The guidelines state that no strong evidence supports one blade design over another. Both hyperangulated and Macintosh-profile video laryngoscopes work. Each requires a different technique. Local provision should reflect equipment availability, training, and clinical case mix.
Do the DAS 2025 guidelines apply to routine intubations or only to difficult airways?
The DAS 2025 guidelines address unanticipated difficult tracheal intubation in adults. However, the first-line video laryngoscopy recommendation applies to all Plan A intubation. Airway difficulty is not always predictable in advance. First-attempt success improves patient safety regardless of predicted difficulty.
Are the DAS 2025 guidelines relevant outside the UK?
Yes. DAS is a UK society, but the guidelines carry international influence. The ASA 2022 guidelines and the CAFG recommendations both point in the same direction on video laryngoscopy adoption. The evidence base underpinning DAS 2025 informs all major airway guidelines globally.
How should a department justify additional video laryngoscopy units to its procurement team?
Cite the DAS 2025 guidelines as the clinical anchor. Add the Cochrane meta-analysis and the 2024 JAMA trial. Make the patient safety case using first-attempt success data. Raise the medicolegal compliance issue. Then present a total cost of ownership comparison that includes the cost of failed intubation episodes.
