Rescuing the stylet: how technique can close the gap in hyperangulated videolaryngoscopy

The trial by Taboada et al. [1] showed superior first-attempt tracheal intubation success with a flexible-tip bougie compared with a stylet when using a hyperangulated videolaryngoscope in patients who were critically ill. While the manoeuvrability of the bougie offers advantages, we believe that the results also highlight how adjustments in technique could improve stylet performance substantially, rescuing it from perceived inferiority.

Taboada et al. shaped the stylet with a 30–40° angulation in the distal 5 cm of the tracheal tube (‘hockey stick’ shape) [2]. This shape is used commonly for direct laryngoscopy or Macintosh videolaryngoscopy but may not replicate the curvature of hyperangulated blades such as the C-MAC® D-Blade (Karl Storz Endoscopy-America, Inc., El Segundo, CA, USA) used in the study. In contrast, Köhl et al. used the same videolaryngoscope with the manufacturer-designed hyperangulated stylet (C-MAC Guide™), achieving a 99% first-attempt success rate in patients with anticipated difficult airways [3]. This suggests that mismatched blade-stylet geometry, rather than intrinsic limitations of the stylet, may have contributed to the lower success observed in the stylet group in the study by Taboada et al.

Notably, both groups achieved excellent glottic visualisation (modified Cormack and Lehane grade 1 view in 96% of the bougie group and 90% in the stylet group). Despite this, the stylet group had a lower first-attempt tracheal intubation success rate (83% vs. 99%) and a higher rate of laryngeal manipulation (31% vs. 10%). These findings support previous observations that overexposure of the glottis may hinder tube delivery by increasing the angle between the tracheal tube and tracheal inlet [2, 4]. A full glottic view is not always favourable; deliberate limitation of blade insertion to achieve a grade 2a or 2b view may, paradoxically, make tracheal intubation easier, especially when using a stylet. Gu et al. showed that limiting glottic exposure improved tracheal intubation speed and ease, despite similar overall success rates [5].

While flexible-tip bougies are useful adjuncts, they are not available in many clinical environments. In such settings, technique becomes paramount. A practical alternative involves shaping a standard malleable stylet to match the blade's curvature, limiting blade insertion depth to avoid excessive angulation and withdrawing the stylet as the tracheal tube passes the vocal cords. These pragmatic, evidence-based refinements [2-4] may help close the performance gap between bougie and stylet, particularly in environments where specialised equipment is unavailable.

In summary, the work of Taboada et al. provides valuable insight into how performance differences between adjuncts may reflect not only device characteristics but also how those devices are used. Emphasising these pragmatic refinements can promote more consistent training, reduce reliance on niche adjuncts and broaden access to safe airway management across diverse practice settings. Future studies should consider standardising hyperangulated videolaryngoscope techniques and reporting key technical variables – such as stylet shaping, glottic view grade and blade insertion depth – to allow more meaningful interpretation of outcomes.