We Can See Clearly Now That Video Is Here
Videolaryngoscopy in Infants.
Anesthesia and analgesia
Submitted June 2026 by Dr Su May Koh
Review summary
This excellent editorial highlights the current evidence for videolaryngoscopy (VL) in improving first pass success rates for intubations in infants compared to direct laryngoscopy (DL). It also stresses the need for a culture change in the way we view VL and how we should teach our trainees.
Key findings
The authors highlight that numerous clinical trials over the last 5 years have repeatedly demonstrated a dramatic improvement in first pass success rates during infant intubations with VL compared to DL. However, there remain a somewhat slower rate of VL adoption from paediatric anaesthesiologists which is not due to a lack of access issue.
Interestingly in Bai et al's recent survey of paediatric anaesthesiologists only 40% would use VL as an initial airway technique in premature infants and neonates, despite 93% of respondents having access to VL in the OR. Uchimani et al recently also showed that the benefits of VL was pronounced in novice trainees with first pass success rates in infants for first year trainees with VL at 86.9% compared to DL at 74.6%.
The authors argue that it is time for all of us to embrace VL for infants and neonates and that whilst fundamental infant laryngoscopy skills are still important - babies do not need to pay the price for this. Also, that DL skills can still be effectively taught using a standard (non-hyperangulated) VL blade. The authors compared this to the use of ultrasound in neck internal jugular (IJV) line insertions as well, suggesting that surely we would NOT advocate abandoning ultrasound for IJV line insertions.
The authors also advocate that we as supervisors must be deliberate in our coaching and feedback during the procedure and suggests a standardized coaching language. VL with trainees also clearly allows a shared mental model, real-time feedback and improved visualisation for the trainee and supervisor. The authors argue that VL should be used a first line in infants and neonates and as skills improve a graduated transition can occur to allow DL skills to develop. Significant blood or vomitus in the airway or failure of the VL equipment, may limit the VL views so DL skills are still important.
Strengths and Limitations
This is an excellent review of the recent literature with key points highlighted well. It is well structured and well argued. Although the authors don't specifically mention this - one also wonders if operator ego is another factor leading to a slowed uptake of VL in the neonatal and infant group.
Bottom line
The evidence for VL as first line in neonates and infants is clear - we should all be using VL as first line as it improves our first pass success rates. This has been a definite change in my practice over the last 5 years and I also insist that my trainees should use standard VL as first line in this population as it improves real-time coaching and teaching. As the authors so rightly point out - why should babies have to pay the price!
