Videolaryngoscopy in infants was linked to lower first-pass success in real-world use

Design

Multicentre retrospective registry cohort with propensity weighting

Population

3,250 tracheal intubations in neonates and infants, J-PEDIA registry, 2022-2025

Primary outcome

First-attempt intubation success

Effect

aRR 0.89 (95% CI 0.83-0.96); desaturation aRR 2.18

Using the Japan Pediatric Difficult Airway in Anesthesia (J-PEDIA) registry from 2022 to 2025 (BJA, 23 September 2026), investigators compared videolaryngoscopy with direct laryngoscopy for the first intubation attempt in 3,250 neonate and infant encounters, adjusting with propensity-score weighting.

Videolaryngoscopy gave a better view (glottic opening score higher by 17.8 points) but was associated with lower first-attempt success (adjusted RR 0.89, 95% CI 0.83-0.96) and more than double the risk of desaturation (adjusted RR 2.18). Respiratory adverse events were similar.

Randomised trials in neonates have favoured videolaryngoscopy, and guidelines recommend it. The authors interpret this gap as an efficacy-effectiveness problem: a better view does not guarantee a faster tube without structured training and technique, particularly in small infants.

• Train specifically in infant videolaryngoscopy; a better view does not automatically mean faster intubation.
• Set a time or saturation limit for each attempt, whichever device is used.
• Use apnoeic oxygenation where your practice supports it to lengthen safe apnoea time.
• Audit first-pass success by device in your own department.

Why it matters

It challenges the assumption that switching to videolaryngoscopy will by itself make infant intubation safer.

Don't overread it

This was observational; operators may have chosen videolaryngoscopy for harder airways, and current guidance has not changed.

The statistics, in plain English

An adjusted RR of 0.89 means about 11% lower relative chance of first-pass success. Propensity weighting cannot correct for unrecorded reasons a clinician picked the video device.

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