Video laryngoscopy as the standard of care for pediatric intubation—the time is now

Tracheal intubation is a lifesaving procedure and one of the foundational practices in the fields of neonatology and pediatric critical care medicine.In the February 2023 issue of Lancet Child & Adolescent Health, Riva and colleagues (1) published the pivotal study entitled "Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial".Based on the preponderance of their findings, they concluded that "video laryngoscopy with oxygen should be considered as the technique of choice when neonates and infants are intubated" (1).In this invited Editorial Commentary for Translational Pediatrics, we discuss the salient results of the study by Riva and colleagues (1), and contextualize their findings relative to existing data on the use of video laryngoscopy in neonates and across the pediatric population.Children require tracheal intubation for various elective, urgent, and emergent reasons across diverse medical care environments such as the operating room, intensive care unit, emergency department, general inpatient areas, and out-of-hospital settings.Even in the hands of seasoned providers under controlled conditions, intubating neonates and small infants can be challenging, given their heightened susceptibility to adverse events during the procedure.This vulnerability stems largely from their elevated oxygen consumption relative to older children and adults, coupled with a high chest wall compliance that results in a functional residual capacity near or below the closing capacity.Consequently, infants may rapidly develop hypoxemia when they enter the relaxed state typical of anesthetic induction.Furthermore, their immature nervous system increases the risk of bradycardia from laryngeal manipulation during the procedure.Adverse event rates ranging from 18% (2) to 68% (3) have been reported during intubations in the neonatal intensive care unit (NICU), with oxygen desaturation occurring in 39-51% (2-4).The high incidence of adverse events has led to the development of various strategies to enhance safety during neonatal intubation.These include the use of individualized airway bundles (5), premedication (6), stylets (7,8), high-flow nasal cannula oxygen supplementation during intubation attempts (3), simulation training (9), and video laryngoscopy (10).The latter has been the subject of intense debate, considering the fact that direct laryngoscopy has been the primary approach for neonatal intubation for decades.Tracheal intubation of anesthetized infants in the operating room using video laryngoscopy has been shown to result in a significantly higher first-attempt success rate compared to direct laryngoscopy [93% vs. 88%; adjusted absolute risk difference 5.5%; 95% confidence interval (CI): 0.7% to 10.3%; P=0.024], and a significantly lower rate of severe complications (2% vs. 5.5%; adjusted absolute risk difference -3.7%; 95% CI: -6.5% to -0.9%; P=0.0087) (11).