Videolaryngoscopy was linked to lower first-attempt success and more desaturation in infant intubation

Design

Retrospective multicentre registry cohort with propensity weighting

Population

3250 intubations in neonates and infants (J-PEDIA registry)

Primary outcome

First-attempt tracheal intubation success

Effect

Adjusted RR 0.89 (0.83 to 0.96); desaturation RR 2.18 (1.57 to 2.79)

Videolaryngoscopy is increasingly recommended for neonates and infants on the strength of better glottic views in trials. This retrospective study of the multicentre Japan Pediatric Difficult Airway in Anesthesia registry analysed 3250 intubations between 2022 and 2025, weighting for confounders.

Videolaryngoscopy gave better glottic opening scores (by 17.8 percentage points) but was associated with lower first-attempt success (adjusted RR 0.89, 95% CI 0.83 to 0.96) and more than double the risk of desaturation (RR 2.18). Respiratory adverse events overall did not differ.

The authors describe an efficacy-effectiveness gap: a better view does not automatically mean a faster, successful tube in routine hands. Operator experience, device and blade choice, and whether videolaryngoscopy was chosen for anticipated difficulty all may have played a part. The conclusion is not to abandon videolaryngoscopy but to implement it with structured training.

• Do not assume a better view on the screen means an easier tube in a small infant
• Train on the specific device and blade size before using it as first choice in neonates
• Use apnoeic oxygenation and a strict attempt time limit whichever laryngoscope you use
• Stop and reoxygenate at the first sign of desaturation
• Audit first-pass success by device in your own department

Why it matters

Guidelines recommending videolaryngoscopy assume a benefit that may not survive outside trial conditions.

Don't overread it

This is observational registry data; videolaryngoscopy may have been chosen for harder airways despite adjustment.

The statistics, in plain English

An adjusted risk ratio of 0.89 means about 11% lower chance of first-pass success. Weighting adjusts for recorded factors; unrecorded reasons for choosing a device may remain.

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