Design: Multicentre randomised controlled trial (NasoVISI)
Population: 673 infants ≤1 year needing nasotracheal intubation for cardiac procedures, 8 US centres
Primary outcome: First-attempt intubation success
Effect: 83% vs 75%; adjusted risk difference 8.2% (2.0–14.3)

NasoVISI, a multicentre randomised trial at eight US paediatric cardiac centres published in The Lancet Child & Adolescent Health on 27 October, enrolled 684 infants up to one year old without anticipated difficult airways who needed nasotracheal intubation for cardiac surgery or catheterisation. The median age was 14 weeks and mean weight 4.8 kg.

First-attempt success was 83% with videolaryngoscopy and 75% with direct laryngoscopy (adjusted risk difference 8.2 percentage points, 95% CI 2.0–14.3). Complications at first attempt (13% vs 12%) and across all attempts (14% in each group) were similar. There were no cardiac arrests or deaths.

The trial adds nasal intubation to evidence already favouring videolaryngoscopy for oral intubation in infants. It was done by experienced clinicians in elective settings; whether the benefit holds in urgent intubation, difficult airways and non-specialist units is not known.

Where available, consider videolaryngoscopy as the first-line device for infant intubation, oral or nasal.
Fewer attempts matter in infants, who desaturate quickly; first-attempt success is the outcome to optimise.
Train and maintain skills with videolaryngoscopy, including in neonatal and paediatric units outside theatres.
Keep direct laryngoscopy skills current, since the result has not been shown in emergencies or difficult airways.

Why it matters

It extends the case for videolaryngoscopy in infants to nasal intubation, without any increase in complications.

The statistics, in plain English

A risk difference of 8.2 percentage points means about 8 more first-attempt successes per 100 infants; the interval (2.0 to 14.3) excludes zero. Complication rates were similar, but the trial was not designed to show a difference in rare serious events.