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Impact of Difficult Laryngoscopy on First-Pass Success and Adverse Events in Pediatric Emergency Department
Tom Solan1,2,3, Stefan Sabato4,5, Hatem Alkhouri6,7
1Department of Emergency Medicine, The Royal Children's Hospital, Victoria, Australia.
Insights
Difficult laryngoscopy occurs in 7.5% of pediatric emergency airway management. This complication significantly reduces first-pass success and increases adverse events like hypoxemia.
Area of Science:
- Emergency Medicine
- Pediatric Critical Care
- Airway Management
Background:
- Pediatric airway management in the Emergency Department (ED) presents unique challenges.
- Difficult laryngoscopy is a known risk factor for reduced first-pass success and increased complications.
- Limited data exist on difficult laryngoscopy specifically within pediatric ED settings.
Purpose of the Study:
- To determine the incidence of difficult laryngoscopy during pediatric intubations in the ED.
- To evaluate the impact of difficult laryngoscopy on first-pass success (FPS).
- To assess the association between difficult laryngoscopy and adverse events in pediatric intubations.
Main Methods:
- Prospective, observational study utilizing the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR).
- Included 865 pediatric intubations across 55 sites (25 PREDICT sites) from 2012-2025.
- Defined difficult laryngoscopy as Cormack-Lehane Grade 3 or 4 on the first attempt; analyzed FPS and adverse events.
Main Results:
- Difficult laryngoscopy (Cormack-Lehane Grade 3-4) occurred in 7.5% of pediatric ED intubations.
- First-pass success was significantly lower in difficult laryngoscopy cases (41.5% vs. 87.9%).
- Adverse events, including hypoxemia and esophageal intubation, were more frequent with difficult views.
Conclusions:
- Difficult laryngoscopy is infrequent but significantly impacts pediatric ED intubation outcomes.
- Findings highlight the need for quality improvement initiatives in pediatric airway management.
- Emphasizes the value of registry data for understanding and managing rare but critical events.
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.
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