Impact of Difficult Laryngoscopy on First‐Pass Success and Adverse Events in Pediatric Emergency Department Intubations
Year: 2026
Type: article
Study design: Observational Study
Abstract: BACKGROUND: Airway management in the Emergency Department (ED) can be challenging, particularly in children. Difficult laryngoscopy reduces first-pass success and increases complications, but pediatric ED data remain limited. METHODS: We conducted a prospective, observational study of pediatric intubations recorded in the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) between 2012 and 2025, including 25 Pediatric Research in Emergency Departments International Collaborative (PREDICT) sites. The primary outcome was the incidence of difficult laryngoscopy. Secondary outcomes were the impact of difficult laryngoscopy on First-Pass Success (FPS) and adverse events. The main exposure variable was laryngoscopic grade, defined as difficult when a Cormack-Lehane Grade 3 or 4 view was encountered on the first attempt. Patient, procedural, and operator characteristics were assessed as potential confounders. RESULTS: Of 946 pediatric ED intubations recorded across 55 sites (including 25 PREDICT pediatric sites) between 2012 and 2025, 865 were included in the analysis after exclusion of cases with missing laryngoscopic grade. The median age was 3.5 years. Difficult laryngoscopy (Cormack-Lehane grade 3-4) was observed in 65 cases (7.5%). FPS was significantly lower in patients with a difficult view compared with those with a non-difficult view (41.5% vs. 87.9%; OR 0.10, 95% CI 0.06-0.17). Adverse events were more frequent in the difficult-view group, including hypoxaemia (38.5% vs. 11.5%; OR 4.81, 95% CI 2.79-8.29) and esophageal intubation (15.4% vs. 1.3%; OR 14.36, 95% CI 5.73-35.98). CONCLUSION: Difficult laryngoscopy in pediatric ED intubations is relatively infrequent but associated with reduced FPS and increased complications. These findings emphasize the importance of ongoing quality improvement and may help inform training and escalation strategies. Continued registry participation is valuable to capture these low-frequency events and better understand their consequences.
Source: Pediatric Anesthesia
DOI: 10.1002/pan.70242
Authors: Tom Solan, Stefan Sabato, Hatem Alkhouri, Michael Dinh, Katie Reeves, Andrew Tagg, Nathan Forsyth, Bernard McCarthy, Eleanor Loughhead, Ben Lawton, Matthew Gorman, Jeremy Furyk, Frances Kinnear, Andrew Brainard, Meredith L. Borland, Shane George, Amit Kochar, Simon Craig, Franz E. Babl, Elliot Long
Institutions: Royal Children's Hospital, The University of Melbourne, Murdoch Children's Research Institute, The University of Sydney, NSW Agency for Clinical Innovation, Royal Prince Alfred Hospital, Children's Health Queensland Hospital and Health Service, Sunshine Hospital, Princess Margaret Hospital for Children, Perth Children's Hospital, Royal Hobart Hospital, Logan Hospital, Redcliffe Hospital, Deakin University, Geelong Hospital, The University of Queensland, University of Auckland, Middlemore Hospital, The University of Western Australia, Griffith University, Women's and Children's Hospital, The University of Adelaide, Monash Medical Centre, Monash Health, Monash University
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7164937173