Video Laryngoscopy for First-Pass Intubation Success in Pediatric Emergency Department Patients
Video laryngoscopy is the best-supported intervention to directly increase first-pass endotracheal intubation success rates in children in the Emergency Department, particularly for anticipated difficult airways or after failed direct laryngoscopy.
Primary Recommendation
The French Society of Anaesthesia and Intensive Care recommends using videolaryngoscopy as the first-line option for patients with anticipated difficult intubation but possible mask ventilation, or after failure of direct laryngoscopy, to increase the probability of successful intubation (Grade 2+). 1 This recommendation specifically notes that videolaryngoscopy can improve glottic vision, the Cormack-Lehane score, and increase the success rate of tracheal intubation at first attempt in children with a history of difficult intubation or polymalformative syndrome. 1
The evidence supporting videolaryngoscopy is particularly strong in the pediatric intensive care setting, where guidelines recommend its use either initially or after failure of direct laryngoscopy to limit intubation failure in children. 1
Supporting Evidence for Video Laryngoscopy
Clinical Trial Data
A 2023 multicenter randomized controlled trial in neonates and infants demonstrated that video laryngoscopy with standard blades achieved 89.3% first-attempt success compared to 78.9% with direct laryngoscopy (adjusted absolute risk difference of 9.5%, p=0.033). 2 This represents the most recent and highest-quality evidence directly addressing the question.
A large multicentre prospective observational study including 1,053 intubations found significantly enhanced first-attempt success with videolaryngoscopy in pediatric intensive care settings. 1
Important Nuances and Limitations
The evidence shows some important context-dependent findings:
In routine (non-difficult) airways without anticipated difficulty, the success rate and time to intubate with videolaryngoscopy are not significantly different from direct laryngoscopy using a Macintosh blade. 1 This suggests the benefit is most pronounced in challenging scenarios.
A 2016 retrospective cohort study in a pediatric ED found no difference between direct and video laryngoscopy for first-pass success (71% vs 72%), complication rates, or successful intubation by ED providers. 3 However, this study had limitations including its retrospective design and the specific VAL technique used (C-MAC with real-time supervisor guidance).
Why Other Options Are Less Supported
Preoxygenation
While preoxygenation is critical for safety (children desaturate rapidly due to higher metabolic oxygen consumption and lower functional residual capacity 4), it does not directly increase first-pass success rates—it extends safe apnea time. The 2023 trial showed that even with supplemental oxygen provided to both groups, video laryngoscopy still demonstrated superior first-pass success. 2
Premedication with Atropine
The guidelines emphasize rapid-onset muscle relaxants (succinylcholine or rocuronium) for optimal intubation conditions 1, but atropine premedication is not specifically recommended to increase first-pass success rates in the available evidence.
Fiberoptic Laryngoscopy
Fiberoptic intubation is recommended only as a rescue technique through a supraglottic airway device and only by trained practitioners. 4 It is not a first-line approach for increasing first-pass success.
Uncuffed Endotracheal Tubes
The evidence actually supports the opposite: cuffed tubes are preferred in children in intensive care units to limit the number of reintubations for leakage (Grade 2+). 1 The American Academy of Pediatrics recommends using cuffed endotracheal tubes with cuff pressure ≤20 cm H2O to reduce re-intubation rates without increasing laryngeal complications. 4
Practical Implementation Considerations
When to Use Video Laryngoscopy
Videolaryngoscopes should be used by trained practitioners in patients with difficult intubation criteria. 1 The device should not be used if: 1
- The patient's mouth opening does not allow device introduction
- The cervical spine is fixed in flexion
- An obstacle producing stridor is present in the upper airway
Technical Considerations
- External laryngeal maneuvers are facilitated when using a videolaryngoscope with a remote screen because their effect is directly visible by the assistant. 1
- When using a videolaryngoscope without a lateral channel, use a non-traumatic preformed guide to direct the tracheal tube toward the glottic aperture. 1
- The performance depends on the type of device, operator expertise, and individual patient characteristics. 1
Critical Pitfall to Avoid
The American Society of Anesthesiologists recommends limiting direct laryngoscopy attempts to a maximum of 2 tries by the most senior practitioner present, with adequate depth of anesthesia, optimal head positioning, gastric decompression, and application of CPAP before each attempt. 4 After 2 failed attempts, proceed to alternative techniques including videolaryngoscopy or supraglottic airway insertion. 4