Mary Lyn Stein

Summary: Introduction: Difficult tracheal intubation is associated with serious complications, including hypoxia, bradycardia and cardiac arrest. Neonates have increased physiologic vulnerability compared with older children, yet detailed data on management strategies and outcomes in neonates with difficult tracheal intubation remain limited. We hypothesised that clinicians have lower first‐attempt tracheal intubation success and higher complication rates for neonates compared with older children with difficult tracheal intubation. Methods: We analysed the Pediatric Difficult Intubation Registry to determine tracheal intubation first attempt success and incidence of complications. We used logistic regression to identify variables associated with complications in neonates. Results: During the study period, 6283 paediatric difficult tracheal intubations were recorded, including 420 neonates. First attempt success was lower for neonates (139/420, 33.1%) than older children (2394/4683, 51.1%). Complications occurred more frequently in neonates (123/420, 29.3%) than older children (637/4683, 13.6%). Hypoxia occurred in 92/420 (21.9%) neonates and 269/4683 (5.7%) older children. Severe complications were more frequent in neonates vs. older children (12/420, 2.9% vs. 30/4683, 0.6%, respectively), with cardiac arrests occurring in 4/420 (1.0%) neonates and 11/4683 (0.2%) older children. Difficult mask ventilation occurred more frequently in neonates (60/420, 14.3%) than older children (353/4681, 7.5%). In neonates, increased number of tracheal intubation attempts (aOR 1.61 per attempt, 95%CI 1.30–2.00, p < 0.001) and difficult facemask ventilation (aOR 3.17, 95%CI 1.38–7.30, p = 0.007) were associated with complications. Anticipated difficulty with airway management had a protective effect (aOR 0.37, 95%CI 0.16–0.88, p = 0.025). Discussion: Neonates with difficult tracheal intubation experience a substantially higher rate of complications than older children. Early recognition of risk is critical in order to enable careful planning to minimise tracheal intubation attempts in this vulnerable population.

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Background: While randomized trials show standard blade video laryngoscopy (SVL) improves first attempt tracheal intubation success in neonates and infants, data on outcomes following adoption in routine clinical practice are limited. We hypothesized that SVL use would increase over time and would be associated with higher first attempt success, fewer difficult intubations, and less hypoxemia during induction. Aims: Our primary aims were to report first attempt success and incidence of difficult intubation. Secondary aims included evaluation of temporal trends in SVL use and association of modifiable factors with hypoxemia at induction. Methods: Following IRB approval, we retrospectively reviewed anesthetics with tracheal intubation for noncardiac procedures in neonates and infants < 2 months of age at our institution from August 2012 to May 2024. Group comparisons were made using Fisher's exact test or the Chi‐square test. Trends over time were analyzed using the Cochran‐Armitage test of trend. Multivariable logistic regression identified factors independently associated with airway outcomes. Results: First attempt tracheal intubation success was 80.4% (2994/3724); incidence of difficult intubation was 5.0% (186/3724). Hypoxemia at induction occurred in 5.5% (205/3724), and airway‐related cardiac arrest occurred in 0.2% (6/3724). First attempt success increased over time, paralleling increased SVL use. SVL use was associated with increased odds of first attempt success (85.9%,1381/1607 SVL vs. 76.2%,1613/2117 direct laryngoscopy (DL), aOR 1.77 95% CI 1.48, 2.12, p < 0.001) and decreased odds of difficult intubation (3.1%, 49/1607 SVL vs. 6.5%, 137/2117 DL, aOR 0.47, 95% CI 0.33, 0.66, p < 0.001). Each additional intubation attempt was strongly associated with hypoxemia at induction. Conclusions: We found clinically important improvements in first attempt tracheal intubation over time. These changes occurred in the context of increased SVL use in conjunction with other practice changes in airway management. We advocate routine SVL use in neonates and young infants with the goal of minimizing the number of intubation attempts, a key target for reducing hypoxemia at induction.

Background: Although clinical trials are fundamental to advancing evidence‐based practice, significant heterogeneity in outcome reporting poses a considerable challenge to the validity of systematic reviews. This inconsistency impedes the ability to compare, synthesise and interpret research findings effectively. In the field of paediatric airway management, this issue is particularly relevant because of the low incidence of critical events and the related high morbidity and mortality. The issue of inadequate and variable outcome reporting in clinical trials has been widely acknowledged, necessitating initiatives to enhance the quality of future research. Objective: This protocol delineates the methodology used for the development of standardised, consensus‐based outcome definitions and reporting items specifically tailored to paediatric airway management trials. The goal is to create guidance that will serve as an extension to the established SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) and CONSORT (Consolidated Standards of Reporting Trials) frameworks, leading to enhanced trial reproducibility and transparency and ultimately improve pediatric airway research, systematic reviews and advance patient care and safety. Methods: This project will adhere to the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network's framework for guideline development. The methodology will be structured into four distinct phases: (1) a scoping review to comprehensively identify outcomes and variables currently reported in paediatric airway management trials; (2) a three‐round Delphi process involving a multidisciplinary panel of experts to prioritise and refine outcomes and variables; (3) a consensus meeting to achieve agreement on the final set of reporting items, which will then be prepared for publication and (4) dissemination. Conclusions: The finalised outcome reporting guidelines, in the form of SPIRIT and CONSORT extensions for paediatric airway management, will be disseminated through various channels to maximise their reach and impact. These include publication in peer‐reviewed journals, presentation at major international conferences and submission to relevant international reporting registries, such as the EQUATOR, SPIRIT and CONSORT registries. Active engagement with key stakeholders, including journal editors, research funders, regulatory bodies and clinician networks and national and international societies, will be a crucial component of the dissemination strategy.

Summary: Introduction: Flexible bronchoscopy is the gold standard for difficult airway management. Clinicians are using videolaryngoscopy increasingly because it is perceived to be easier to use with high success rates. We conducted this study to compare the success rates of the two techniques when used after failed direct laryngoscopy in children with difficult tracheal intubations. Methods: We identified cases where initial attempts at direct laryngoscopy failed in the multicentre Pediatric Difficult Intubation Registry from August 2012–September 2023. After propensity score matching, we compared success rates and complications when videolaryngoscopy and flexible bronchoscopy were used as rescue techniques in the matched cohort and in matched patients weighing < 5 kg. Results: Clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy when direct laryngoscopy failed (64.7%, 1426/2281 vs. 7.3%, 156/2281, p < 0.001). Propensity score matched cohorts did not differ with respect to first‐attempt success, eventual success and complications. For the subgroup of infants < 5 kg, clinicians chose videolaryngoscopy more frequently than flexible bronchoscopy to rescue failed direct laryngoscopy (54.3%, 295/543 vs. 8.9%, 44/543, p < 0.001). First‐attempt success was 43% (62/145) with videolaryngoscopy and 62% (18/29) with flexible bronchoscopy (odds ratio 2.19, 95%CI 0.96–4.98, p = 0.061). Eventual success was 71% (103/145) with videolaryngoscopy and 90% (26/29) with flexible bronchoscopy (odds ratio 3.53, 95%CI 1.03–12.2, p = 0.046). Complications did not differ between the techniques. Discussion: Videolaryngoscopy was chosen more frequently than flexible bronchoscopy as a rescue technique in a cohort of children with difficult direct laryngoscopy, with similar success and complication rates. For small infants, flexible bronchoscopy had a higher eventual success rate, underscoring the importance of maintaining proficiency with flexible bronchoscopy.