Initial Laryngoscope Blade Selection and Outcomes in Paediatric Emergency Department Intubations: Miller vs....

Optimal initial laryngoscope blade selection for paediatric emergency intubation is uncertain. We examined whether Miller or Macintosh blades are associated with differences in first-pass success (FPS) and adverse events in children < 5 years.

Prospectively collected data from the Australia and New Zealand ED Airway Registry (ANZEDAR) between March 2010 and March 2024 were analysed for children under 5 years of age. We report demographics, FPS and adverse events by initial blade type. Multivariable models examined factors associated with FPS and hypoxia.

Among 201 children, 88 (43.8%) were intubated with a Miller blade and 113 (56.2%) with a Macintosh blade. In unadjusted analyses, children intubated with Miller blades were younger (median 0.4 years, IQR 0.08-1.35 vs. median 1.6 years, IQR 0.75-2.00), p < 0.001), had lower FPS (63.6% vs. 80.5%; OR 0.42, 95% CI 0.22-0.80; p = 0.008) and had a higher incidence of hypoxia (33.0% vs. 17.7%; OR 2.28, 95% CI 1.19-4.46; p = 0.01) compared with children intubated with Macintosh blades. Hypotension rates did not differ.

In this cohort of young children intubated in the ED, Macintosh blade use was associated with higher FPS and fewer hypoxic events compared with Miller blade. Age was a significant confounder and should be considered when choosing which laryngoscope blade to use in young children.