From algorithms to adaptation: a Safety-II view of the 2025 Difficult Airway Society Difficult Airway Guidelines.

Abstract

The 2025 Difficult Airway Society guidelines for unanticipated difficult tracheal intubation represent a conceptual evolution in airway management, aligning closely with Safety-II and resilience engineering principles. Rather than focusing predominantly on failure prevention, the new guidelines prioritise continuous oxygenation, timely escalation, human factors, and a broader understanding of airway difficulty that incorporates physiological and contextual complexity. These features support adaptive clinical performance and legitimise escalation as an appropriate response to system variability, which aligns with Safety-II principles. The accompanying education and implementation resources provide an opportunity to translate these principles into practice. The impact and effectiveness of the 2025 Difficult Airway Society guidelines will depend on how they are interpreted and embedded within local contexts and how well they enhance clinicians' capacity to move beyond everyday compliance (Safety I) to adapting to complexity under pressure (Safety-II).