H. Lin Jia Qi1, R. Lin2, K. Ong2

1London North West University Healthcare NHS Trust, London,  UK

2Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK

Introduction and aims

The relative success rates of various techniques for endotracheal intubation in children with difficult airways have been documented in publications from the international Pediatric Difficult Intubation (PeDI) registry (1,2). The primary aim of this analysis is to compare the success rates of common techniques used in difficult intubation (direct laryngoscopy, videolaryngoscopy and the hybrid technique of simultaneous videolaryngoscopy with flexible fibreoptic bronchoscopy) against the PeDI registry. Our secondary aim is to determine the incidence of complications related to intubation.


We reviewed all electronic records of a tertiary referral paediatric hospital. Difficult intubation was defined either by PeDI criteria or by intubation requiring three or more attempts. Age, weight, intubation attempts, techniques and complications were recorded. Complications are as per the PeDI registry and are modified from the National Emergency Airway Registry for Children (NEAR4KIDS) operational definitions. The presence of hypoxaemia was defined as SpO2 <80% (3).


From September 2019 to January 2024, 540 cases of difficult intubation were identified. 297 patients (55.0%) were male. Median age was 57.5 ((9.0-145.0) [0.0-216.0]) months and median weight was 15.9 ((7.6-30.1) [2.0-93.5]) kg. 397 patients (76.3%) had a syndrome diagnosis.

The most commonly attempted first intubation technique was videolaryngoscopy (n=231, 42.8%) followed by direct laryngoscopy (n=178, 33.0%) and the hybrid technique (n=92, 17.0%). With reference to Figure 1, first attempt success rate was lowest for direct laryngoscopy (n=19, 10.7% versus 1% in PeDI) compared to 60.2% (n=139) for videolaryngoscopy (versus 43-58% in PeDI) and 76.1% (n=70) for the hybrid technique (versus 60% in PeDI) (4). Amongst patients weighing less than 10kg (n=180), direct laryngoscopy was the most commonly used initial technique (n=91, 50.6%) but had the lowest first attempt success rate (n=13, 14.3%) compared to videolaryngoscopy (n=36, 62.1%) and the hybrid technique (n=16, 69.7%). The eventual success rate in all patients was 98.0%, which was similar across techniques and weight categories.

83 patients (15.4%) had at least one complication. The most common was hypoxaemia (n=48, 8.9%). A multivariate logistic regression model identified having more than two intubation attempts (odds ratio 1.76, p=0.048) and weight less than 10kg (odds ratio 2.79, p<0.001) as significant predictors of presence of complications.



Discussion and conclusion

Our centre has demonstrated a high volume of difficult paediatric intubations, with higher first attempt and eventual success rates across all techniques and lower complication rates as compared to the PeDI registry. However, direct laryngoscopy remains a common initial technique, especially in those weighing less than 10kg. Our findings suggest that techniques other than direct laryngoscopy should be considered as first-line to reduce the number of attempts and complications, especially in infants less than 10kg.


  1. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 2016 Jan;4(1):37–48.
  2. Stein ML, Park RS, Kiss EE, Adams HD, Burjek NE, Peyton J, et al. Efficacy of a hybrid technique of simultaneous videolaryngoscopy with flexible bronchoscopy in children with difficult direct laryngoscopy in the Pediatric Difficult Intubation Registry. Anaesthesia. 2023 Sep;78(9):1093–101.
  3. Graciano AL, Tamburro R, Thompson AE, Fiadjoe J, Nadkarni VM, Nishisaki A. Incidence and associated factors of difficult tracheal intubations in pediatric ICUs: a report from National Emergency Airway Registry for Children: NEAR4KIDS. Intensive Care Med. 2014 Nov;40(11):1659–69.
  4. Park R, Peyton JM, Fiadjoe JE, Hunyady AI, Kimball T, Zurakowski D, et al. The efficacy of GlideScope® videolaryngoscopy compared with direct laryngoscopy in children who are difficult to intubate: an analysis from the paediatric difficult intubation registry. British Journal of Anaesthesia. 2017 Nov;119(5):984–92.
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