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Technical factors associated with first-pass success during endotracheal intubation in children: analysis of videolaryngoscopy recordings
  1. Kelsey A Miller1,2,
  2. Michael C Monuteaux1,2,
  3. Joshua Nagler1,2
  1. 1 Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  2. 2 Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Kelsey A Miller, Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA; kelsey.miller{at}


Background First-pass success (FPS) during intubation is associated with lower morbidity for paediatric patients. Using videolaryngoscopy (VL) recordings, we reviewed technical aspects of intubation, including factors associated with FPS in children.

Methods We performed a retrospective study of intubation attempts performed using video-assisted laryngoscopy in a paediatric ED between January 2014 and December 2018. Data were abstracted from a quality assurance database, the electronic medical record and VL recordings. Our primary outcome was FPS. Intubation practices were analysed using descriptive statistics. Patient and procedural characteristics associated with FPS in univariate testing and clinical factors identified from the literature were included as covariates in a multivariable logistic regression. An exploratory analysis examined the relationship between position of the glottic opening on the video screen and FPS.

Results Intubation was performed during 237 patient encounters, with 231 using video-assisted laryngoscopy. Data from complete video recordings were available for 129 attempts (59%); an additional 31 (13%) had partial recordings. Overall, 173 (73%) of first attempts were successful. Adjusting for patient age, placing the blade tip into the vallecula adjusted OR ((aOR) 7.2 (95% CI 1.7 to 30.1)) and obtaining a grade 1 or 2a-modified Cormack-Lehane glottic view on the videolaryngoscope screen (aOR 6.1 (95% CI 1.5 to 25.7) relative to grade 2b) were associated with increased FPS in the subset of patients with complete recordings. Exploratory analysis suggested that FPS is highest (81%) and duration is shortest when the glottic opening is located in the second quintile of the video screen.

Conclusions Placement of the blade tip into the vallecula regardless of blade type, sufficient glottic visualisation and locating the glottic opening within the second quintile of the video screen were associated with FPS using video-assisted laryngoscopy in the paediatric ED.

  • airway
  • anaesthesia - rsi
  • paediatrics
  • paediatric emergency medicine
  • paediatrics
  • paediatric resuscitation
  • resuscitation

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  • Handling editor Katie Walker

  • Twitter @millerkelseyann

  • Contributors KAM conceived of the study, performed the data collection, analysed the data, drafted and revised the manuscript; MCM analysed the data, drafted and revised the manuscript; JN conceived of the study, performed the data collection, drafted and revised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Boston Children's Hospital Institutional Review Board: IRB-P00028569.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Deidentified data are available upon request from the corresponding author.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.