Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

Study Type: Secondary analysis of the NECTARINE study (European multicentre/multinational prospective observational cohort study). Aim to identify the incidence of difficult tracheal intubation in neonates & infants, along with the associated effect on morbidity & mortality.

Methods: Complex statistical analysis of data from the original NECTARINE study.

Findings: Difficult intubation occurred more commonly (5.8%) than expected. Significant desaturation occurred in 40% of these cases with no identifiable risk factors for this. Fortunately, there was no increase in morbidity or mortality as a result of these events at 30 & 90 days.


The authors identified a higher than expected number of difficult intubations, where the latter is defined as requiring 3 or more attempts at tracheal intubation. This may still be underreported as most of the participating sites were specialised paediatric centres. The rates in non-specialist centres could be even higher. Of concern, 13% of difficult intubations were also difficult to mask ventilate. Nearly half of these patients desaturated significantly during this process. However, through statistical modelling, no identifiable risk factors could be identified indicating that the physiological differences of this age group are the cause for this.

The authors highlighted evidence reporting the benefit of passive oxygen delivery via nasal prongs during laryngoscopy and utilising video laryngoscopes to optimise the first pass success rate. The adult world has demonstrated the power of apnoeic oxygenation via high flow nasal oxygen (HFNO) in the prevention of desaturation during shared airway cases. The HAMSTER trial is currently evaluating this in the paediatric population with encouraging results on the prolongation of oxygen saturation. I suspect the addition of HFNO in neonates and infants will become a standard tool during laryngoscopy in time.

Given the evidence, this population should be considered potentially high risk for difficult intubation and the best available equipment and most experienced personnel should be immediately available during planned airway management. These results also highlight the importance of non-technical skills and communication with your anaesthetic team. Discussing the primary airway plan and backup options, may prevent unrest in the presence of a significant desaturation event.

Reviewed by Dr Nathan Hewitt