I have been increasingly using video laryngoscopy in my practice, both when I myself perform the intubation, and when I am supervising a resident or other trainee. I usually ask them to use a VL when it is a nurse practitioner or RT that is about to intubate also.

It already seemed to me that the evidence was very supportive, with lower failure rates with VL than standard laryngoscopes, and I really appreciate the ability to see what someone else is doing when training them. A recent large RCT in adults with over 8000 procedures showed that the failure of the first intubation attempt was about 7.6% with direct laryngoscopy and only 1.7% with a video device. Intubation failure (needing more than 3 attempts or switching to a different device) was 4% with standard technique, and only 0.26% with the video. Ruetzler K, et al. Video Laryngoscopy vs Direct Laryngoscopy for Endotracheal Intubation in the Operating Room: A Cluster Randomized Clinical Trial. JAMA. 2024;331(15):1279-86.

I wish we could have success rates that high; multiple intubation attempts lead to local trauma, pain, increased physiologic deterioration including spikes in intracranial pressure and are associated with increased IVH. In marked contrast to the above study in adults, a recent single centre randomised study of video versus direct laryngoscopy for nasotracheal intubation in the newborn (n=89) had desperately poor rates of intubation on the first attempt: 49% success on the first attempt with the video, and 44% with direct laryngoscopy. Tippmann S, et al. Video versus direct laryngoscopy to improve the success rate of nasotracheal intubations in the neonatal intensive care setting: a randomised controlled trial. BMJ Paediatr Open. 2023;7(1). Infants received fentanyl and midazolam, some of them received vecuronium “if intubation conditions were considered inadequate after analgesia and sedation”, I have no idea how you can determine this prior to laryngoscopy. Most of the intubation first attempts were by trainees (60%), and the babies were intubated either in the delivery room or the NICU, most were preterm. Although I said first intubation success was “desperately poor”, such results are similar to many other studies which also have very poor success on 1st attempt.

Another multicentre study, performed by anaesthetists in several countries, after induction of anaesthesia, muscle-relaxed newborn infants up to 52 weeks PMA in the Operating Room were randomized to standard or video laryngoscopy for their intubation. (Riva T, et al. Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial. Lancet Child Adolesc Health. 2023;7(2):101-11). First attempt success was 89% with the VideoLaryngoscope (VL) and 79% with the standard blade. These were largely full term infants with a mean PMA of 44 weeks.

What can we do to improve these poor success rates? Well, in addition to the RCTs, there is an ongoing multicentre quality evaluation initiative Near4Neos that has shown that you are more likely to be successful if you use muscle relaxant, and if you use a VL. But overall, in those database studies, success of the first attempt was still very low. With muscle relaxant 56% 1st attempt success, vs 33% with sedation alone, and 58% with the VL, compared to 47% with direct laryngoscopy.

We have also shown, from our centre, that restricting intubations of the highest risk babies to individuals with proven competence improves success rates. Gariépy-Assal L, et al. A tiny baby intubation team improves endotracheal intubation success rate but decreases residents’ training opportunities. J Perinatol. 2022;43(2):215-9. We increased the first attempt success rate from 44% to 59% when junior residents were only allowed to intubate babies <29 weeks after proving competence in larger babies. We also have well organized simulation training, direct supervision by more senior staff, a premedication protocol which is always followed in the NICU and which includes muscle relaxation.

Which brings me to the new trial, presented in Toronto at the 2024 Pediatric Academic Societies meeting, and published the same day in the NEJM. Geraghty LE, et al. Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants. N Engl J Med. 2024. This single-centre RCT from Colm O’Donnell’s unit in Dublin randomised just over 200 babies, in the DR or in the NICU, who required urgent intubation. It therefore included preterm and term infants, and babies in the NICU routinely received premedication, which included a muscle relaxant.

The results showed a dramatic difference.

The paediatric residents success rate went from 40% to 70%, neonatal fellows from 53 to 77%. There were very few performed by staff neonatologists, even though the slide from the presentation in Toronto shows Dr O’Donnell’s ear as he is intubating with a VL:

As you can see from the next figure the advantages applied to small and preterm babies as well as the overall group, in the DR and in the NICU.

The successful first attempts took about 10 seconds longer with the VL (60 vs 50 seconds), but that did not increase the number of babies with major desaturation or bradycardia.

One other new RCT of neonatal intubation compared the use of stylets to no stylet, in contrast to the only previous RCT that I am aware of, which showed a very small difference in success or duration of intubation attempts (from the group in Melbourne, and including Dr O’Donnell as an author), this new trial showed a greater first attempt success with the stylet in intubations in a surgical NICU compared to no stylet. Success of 1st attempt was an impressive 81% with and 73% without stylet among 200 newborn infants, with a mean GA of 36 weeks. (Solanki S, et al. Randomized controlled trial to evaluate the rate of successful neonatal endotracheal intubation performed with a stylet versus without a stylet. Paediatr Anaesth. 2024;34(5):448-53).

Of note, some of my colleagues performed a fascinating trial among paediatric trainees, Michael Assaad and Ahmed Moussa are 2 of my colleagues in Sainte Justine, and Ewa Gizicki was one of our fellows, the other authors of this trial are colleagues from across Quebec. They randomized residents about to intubate a baby to a 10 minute training session (if there was time depending on baby’s condition, of course), which consisted either of a 10 minute video, or “Just In Time” training, which was a 30 second video accompanied by practice on a mannequin, supervised by a staff who used scripted feedback depending on the difficulties experienced. Gizicki E, et al. Just-in-time Neonatal Endotracheal Intubation Simulation Training: A Randomized Controlled Trial. J Pediatr. 2023:113576. First attempt success rate was improved in the JIT group 54% compared to 41%. Rethinking exactly how we train and supervise residents for this important skill has been a focus of my 2 colleagues for a while, this approach requires a lot of the staff supervising, but it seems to work.

I think the accumulation of evidence and this new RCT makes it clear that Video-Laryngoscopy should be considered the standard of care of neonatal endotracheal intubation. It has universally been shown to reduce failure of the 1st intubation attempt, and even though the 1st attempt may be slightly longer, the overall duration of laryngoscopy is much shorter as you are more likely to only do it once!

Optimal Endotracheal Intubation Procedures:

1. Ensure that the appropriate person is doing the procedure, someone who has been well-trained, with the use of simulation before practising on babies.
2. High risk intubations should only be performed by an individual with proven competence. Intubating a 500 gram infant is not the time for a junior resident to “have a try”.
3. If at all possible, the baby should be premedicated, using an analgesic with a rapid onset (not morphine), and a muscle relaxant with rapid onset and short duration of action.
4. Oxygen should be administered during the procedure, preferably by high-flow nasal cannulae.
5. Video-laryngoscopy should be used for all neonatal intubations, both in the DR and in the NICU (note to self, we need to get them available for the transport team also).
6. Senior supervision of trainees is essential, and is also facilitated by Video-Laryngoscopy.

Endotracheal intubation is the most traumatic procedure that we perform frequently in the NICU, multiple intubation attempts harm our babies, and we should do everything possible to reduce their number.