Small Margin
New neonatal and infant airway guidance moves video to the first attempt, oxygen through the attempt, and adaptation after every failure.
An infant airway is not simply a smaller airway. It is a shorter clock.
Neonates and infants bring a larger occiput, a relatively larger tongue, a smaller mouth, a shorter trachea, and laryngeal anatomy that can feel unexpectedly anterior. They also consume oxygen quickly and desaturate fast.
The review cites first-attempt success rates of only 30% to 57%, with peri-intubation adverse events reported in 9% to 50% of cases.
Those numbers should change the way the procedure begins. The goal is not merely to become better at laryngoscopy. It is to build a better system around the attempt.
Video changes the room. It does not replace the system.
A shared view.
The guideline recommends videolaryngoscopy with an age-adapted standard Macintosh or Miller blade as the first choice for neonatal and infant intubation. The screen can improve visualization, support first-attempt success, and let the whole team see what the operator sees.
Oxygen, delivery, rescue.
A good view does not guarantee passage of the tube. Hyperangulated blades may make delivery harder, and blood or secretions may make the camera less useful. Video does not correct poor preoxygenation, inadequate medication, or a rescue plan that was never prepared.
Build the attempt before the attempt begins.
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01 // Oxygen
Keep it flowing.
The guidance supports apneic oxygenation during neonatal intubation. Standard nasal cannula or high-flow nasal oxygen may extend the available apnea period, but neither makes a prolonged attempt safe.
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02 // Medication
Create intubating conditions.
Outside active resuscitation, use adequate sedation or anesthesia and neuromuscular blockade when preservation of spontaneous breathing is not required. Under-medication is not a safety strategy.
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03 // Device
Start with video.
Use an age-appropriate standard-geometry blade first. When a hyperangulated blade is selected, or the larynx is markedly anterior, shape and reinforce the tube with a stylet.
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04 // Rescue
Open it before you need it.
Select and size the supraglottic airway before laryngoscopy. Keep mask ventilation equipment, suction, alternative blades, flexible endoscopy, and multiple tube sizes immediately available.
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05 // Confirmation
Demand a waveform.
Confirm tracheal placement immediately with clinical assessment and sustained waveform capnography. In a short neonatal trachea, tube depth and migration deserve continued attention after the cords are crossed.
Every attempt spends something the patient may not have.
Each attempt consumes oxygen, time, attention, and the condition of the airway. Edema, bleeding, secretions, hypoxemia, and bradycardia can turn the next attempt into a harder one.
The guideline recommends reassessing after every failure and considering a change in technique, provider, or both. Change the position. Change the blade. Add a stylet. Improve suction. Move to a more experienced operator. Use a supraglottic airway. Combine video with flexible bronchoscopy when the situation calls for it.
A second attempt should not be a replay of the first.
The parts of the guideline that should make a department stop and plan.
The invasive rescue is different.
Surgical and percutaneous cricothyroidotomy are not considered suitable for neonates and infants. When intubation fails and oxygenation cannot be maintained by mask or supraglottic airway, emergent tracheostomy is described as the preferred invasive airway.
That is not a procedure most emergency departments routinely rehearse. Hospitals caring for infants need a local plan that identifies who will perform it, what equipment will be used, and how help will be mobilized.
The screen helps. The team still has to work.
The paper gives real attention to communication, hierarchy, fixation, teamwork, and situational awareness. A shared video view can improve coaching, but it does not assign roles, announce a falling saturation, or give a junior clinician permission to stop an unsafe sequence.
Attempt limits, rescue triggers, and the next operator should be discussed before the first blade enters the mouth.
Guideline update: Neonatal and infant airway management
Brit Long and Michael Gottlieb summarize the 2024 joint European guidance with an emphasis on what it means for emergency clinicians.
Long B, Gottlieb M. American Journal of Emergency Medicine. 2026;109:259–262. doi:10.1016/j.ajem.2026.07.056
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