Videolaryngoscopy in infants: better view, but lower first-attempt success in real-world registry data

Design

Retrospective multicentre registry cohort with inverse-probability-of-treatment weighting

Population

3,250 intubation encounters in neonates and infants, J-PEDIA registry, 2022 to 2025

Primary outcome

First-attempt tracheal intubation success

Effect

Adjusted risk ratio 0.89 (95% CI 0.83 to 0.96) for videolaryngoscopy; desaturation adjusted risk ratio 2.18 (1.57 to 2.79)

A retrospective cohort from the Japanese paediatric difficult airway registry analysed 3,250 intubation encounters in neonates and infants between 2022 and 2025. Videolaryngoscopy was compared with direct laryngoscopy using propensity score weighting to balance patient characteristics.

After adjustment, videolaryngoscopy was associated with a lower probability of first-attempt success (adjusted risk ratio 0.89, 95% CI 0.83 to 0.96) and a higher risk of oxygen desaturation (adjusted risk ratio 2.18, 95% CI 1.57 to 2.79). It gave a better percentage of glottic opening score (beta 17.8, 95% CI 9.5 to 26.1). Respiratory adverse events did not differ.

The authors read this as an efficacy-effectiveness gap in non-standardised practice. Registry data cannot exclude that videolaryngoscopy was chosen for harder airways, which propensity weighting only partly handles. The finding supports structured training and teaching technique rather than avoiding the device, and it does not overturn existing recommendations.

• First-attempt success was lower with videolaryngoscopy (adjusted risk ratio 0.89).
• Desaturation was more common (adjusted risk ratio 2.18).
• The view of the glottis was better with videolaryngoscopy.
• Videolaryngoscopy may have been chosen for harder airways, which the weighting cannot fully fix.
• Training in the specific technique matters as much as having the device.

Why it matters

A device that improves the view does not guarantee that the tube goes in first time.

Don't overread it

Retrospective registry data in non-standardised practice cannot show that videolaryngoscopy is inferior in trained hands, and existing recommendations have not changed.

The statistics, in plain English

A risk ratio of 0.89 means first-attempt success was about 11% lower in relative terms. A risk ratio of 2.18 for desaturation means more than twice the risk. Propensity weighting balances measured characteristics only, so unmeasured difficulty may explain some of the gap.

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