Videolaryngoscopy versus direct laryngoscopy for nasotracheal intubation in infants undergoing cardiac procedures (NasoVISI): a multicentre, randomised controlled trial.

Summary

In this multicentre randomized trial of 673 evaluable infants, first-attempt nasotracheal intubation success was significantly higher with videolaryngoscopy than with direct laryngoscopy: 83% versus 75%, with an adjusted risk difference of 8.2%. First-attempt and cumulative complication rates were similar, and no cardiac arrest or death occurred in either group.

Key Findings

• First-attempt nasotracheal intubation success was 83% with videolaryngoscopy versus 75% with direct laryngoscopy.
• The adjusted risk difference in first-attempt success was 8.2% (95% CI, 2.0%-14.3%; p = 0.0093).
• First-attempt and cumulative complication rates were similar, and no cardiac arrest or death occurred.

Clinical Implications

Videolaryngoscopy should be strongly considered as the initial device for nasotracheal intubation in infants undergoing elective cardiac procedures, particularly where trained operators and appropriate equipment are available. The findings should not yet be generalized to anticipated difficult airways, emergency settings, or non-specialist centers.

Limitations

• Participants had no anticipated difficult airway and were treated in specialized pediatric cardiac centers.
• The study does not establish whether the benefit extends to emergency procedures, difficult airways, or non-specialist hospitals.

Future Directions

Future studies should evaluate videolaryngoscopy in infants with anticipated difficult airways, urgent or emergency procedures, and lower-volume centers, while assessing device-specific performance, training requirements, and cost-effectiveness.