Authors: Khan et al.
Pediatric Anesthesia, May 4, 2026
Key Points
This single-center retrospective cohort study evaluated airway outcomes in neonates and infants younger than 2 months undergoing tracheal intubation for noncardiac procedures.
The study reviewed 3,724 anesthetics performed from August 2012 through May 2024.
First-attempt tracheal intubation success was 80.4%, and difficult intubation occurred in 5.0% of cases.
Use of standard blade video laryngoscopy increased over time and was associated with higher first-attempt success and fewer difficult intubations.
Each additional intubation attempt was strongly associated with hypoxemia during induction.
Summary
This study examined whether adoption of routine standard blade video laryngoscopy improved airway outcomes in neonates and young infants. Although randomized trials have shown that video laryngoscopy can improve first-attempt intubation success in this population, less was known about how outcomes change after video laryngoscopy becomes part of routine clinical practice. The investigators reviewed anesthetics requiring tracheal intubation for noncardiac procedures in neonates and infants younger than 2 months at a single institution from August 2012 to May 2024.
The study included 3,724 anesthetics. Overall first-attempt tracheal intubation success was 80.4%, with 2,994 successful first attempts out of 3,724 cases. Difficult intubation occurred in 5.0% of cases. Hypoxemia during induction occurred in 5.5%, and airway-related cardiac arrest occurred in 0.2%. These findings highlight the high-risk nature of airway management in neonates and young infants, even in a specialized pediatric anesthesia setting.
The most important finding was that first-attempt success improved over time as standard blade video laryngoscopy use increased. Compared with direct laryngoscopy, video laryngoscopy was associated with higher first-attempt success. First-attempt success was 85.9% with video laryngoscopy compared with 76.2% with direct laryngoscopy. After adjustment, video laryngoscopy remained independently associated with increased odds of first-attempt success.
Video laryngoscopy was also associated with fewer difficult intubations. Difficult intubation occurred in 3.1% of video laryngoscopy cases compared with 6.5% of direct laryngoscopy cases. After adjustment, video laryngoscopy was associated with significantly lower odds of difficult intubation. This suggests that routine video laryngoscopy may improve both success and consistency of airway management in very young patients.
The study also found that additional intubation attempts were strongly associated with hypoxemia during induction. This is clinically important because neonates and young infants have limited oxygen reserve and can desaturate quickly. The results support a strategy focused on maximizing first-attempt success and minimizing repeated airway attempts.
The authors concluded that clinically important improvements in first-attempt tracheal intubation occurred over time in the setting of increased standard blade video laryngoscopy use and other airway practice changes. They advocated routine video laryngoscopy use in neonates and young infants, with the goal of reducing the number of intubation attempts and lowering the risk of hypoxemia during induction.
What You Should Know
This study supports routine use of standard blade video laryngoscopy for tracheal intubation in neonates and infants younger than 2 months. In this cohort, video laryngoscopy was associated with better first-attempt success and fewer difficult intubations than direct laryngoscopy.
For anesthesia providers, the key practical message is that the first attempt matters. Every additional intubation attempt increases the risk of hypoxemia, and hypoxemia in neonates and young infants can occur rapidly. Strategies that improve first-pass success are therefore especially important in this population.
This study does not prove that video laryngoscopy alone caused all outcome improvements, because other airway management practices also changed over the study period. However, the association between increased video laryngoscopy use and improved outcomes is clinically meaningful and consistent with the broader movement toward video-assisted airway management in high-risk pediatric patients.
Overall, the article supports making video laryngoscopy a routine part of neonatal and young infant airway management rather than reserving it only for anticipated difficult airways.
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