Airway Management in Neonates and Young Infants: Changes in Clinical Outcomes With Adoption of Routine Video Laryngoscopy in a Single Center Retrospective Cohort

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.