Videolaryngoscopy and first-attempt tracheal intubation success in neonates and infants: a retrospective cohort study using the Japan Pediatric Difficult Airway in Anesthesia (J-PEDIA) registry.

BACKGROUND: First-attempt tracheal intubation success is critical in neonates and infants. Although videolaryngoscopy (VL) is recommended for neonatal and infant intubation, uncertainty remains regarding its effectiveness in real-world practice. We evaluated the association between use of VL for the initial tracheal intubation attempt and first-attempt tracheal intubation success in neonates and infants using a multicentre airway registry. METHODS: This retrospective cohort study used data from the Japan Pediatric Difficult Airway in Anesthesia (J-PEDIA) registry, collected between June 2022 and February 2025. The primary outcome was first-attempt tracheal intubation success. Secondary outcomes included the percentage of glottic opening score, respiratory adverse events, and haemoglobin oxygen desaturation. Propensity score-based inverse probability of treatment weighting was applied to adjust for potential confounders. RESULTS: Overall, 3250 encounters were analysed. After inverse probability of treatment weighting adjustment, VL was associated with a lower probability of first-attempt success than direct laryngoscopy (adjusted risk ratio 0.89, 95% confidence interval [CI] 0.83-0.96, P=0.001). VL was also associated with higher percentage of glottic opening scores (β 17.8, 95% CI 9.5-26.1, P<0.001), but increased risk of desaturation (adjusted risk ratio 2.18, 95% CI 1.57-2.79, P<0.001). The incidence of respiratory adverse events was similar between the groups (adjusted risk ratio -0.09, 95% CI -0.012 to 0.0097, P=0.86). CONCLUSIONS: VL use was associated with lower first-attempt tracheal intubation success and a higher risk of desaturation compared with direct laryngoscopy. These findings suggest an efficacy-effectiveness gap in non-standardised real-world practice. Structured VL implementation and targeted training might be required to translate improved visualisation into successful first-attempt tracheal intubation. CLINICAL TRIAL REGISTRATION: jRCT; registration number: 1040250033.