Dr. Vinay Nadkarni, a leading expert in pediatric anesthesiology and co-principal investigator of NEAR4KIDS, dives into the complexities of pediatric tracheal intubation. He highlights how registry data can improve airway management compared to limited pediatric trials. Key topics include the benefits of video laryngoscopy for success rates and the rise of apneic oxygenation. Nadkarni emphasizes tailored approaches for patient positioning and equipment choices, shedding light on practical strategies to enhance outcomes in critically ill children.
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insights INSIGHT
Registry Data Drive Pediatric Airway Knowledge
Pediatric airway evidence mostly comes from registries and observational data rather than RCTs.
NEAR4KIDS lets us find associations but cannot prove causation due to confounding and small numbers.
volunteer_activism ADVICE
Use Apneic Oxygenation Routinely
Use apneic oxygenation during laryngoscopy to prolong time to desaturation.
Tailor nasal cannula flow by age and make exceptions when seal or pre-existing NIV make it inappropriate.
insights INSIGHT
Video Laryngoscopy Has Contextual Benefits
Video laryngoscopy reduces adverse airway events and can improve first-pass success in specific pediatric trials.
Use it both as a primary device in difficult neck mobility and as a coaching/confirmation tool.
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In this World Shared Practice Forum Podcast, Dr. Vinay Nadkarni discusses emergent tracheal intubation in pediatric critical care. Drawing from the NEAR4KIDS registry and comparing with recent adult-focused evidence, Dr. Nadkarni discusses the challenges of airway management in children, emphasizing the importance of patient-specific physiology. He highlights how patient positioning and equipment choices can improve intubation outcomes. Additionally, the episode explores the benefits of video laryngoscopy and apneic oxygenation. This content is pertinent for healthcare professionals seeking to enhance their understanding of pediatric airway management, offering practical insights supported by recent research.
LEARNING OBJECTIVES
- Compare pediatric and adult emergency tracheal intubation evidence and practices
- Explore the role of the NEAR4KIDS registry in improving pediatric intubation practices
- Identify effective strategies to enhance first-attempt success in tracheal intubations
- Assess the impact of patient positioning and equipment choices on intubation outcomes
- Evaluate the benefits of video laryngoscopy and apneic oxygenation in pediatric settings
AUTHORS
Vinay Nadkarni, MD, MS
Professor, Anesthesiology
Critical Care and Pediatrics
University of Pennsylvania Perelman School of Medicine
Jeffrey Burns, MD, MPH
Emeritus Chief
Division of Critical Care Medicine
Department of Anesthesiology, Critical Care and Pain Medicine
Boston Children's Hospital
Professor of Anesthesia
Harvard Medical School
DATE
Initial publication date: November 25, 2025.
ARTICLES REFERENCED
- DeMasi SC, Casey JD, Semler MW. Evidence-based Emergency Tracheal Intubation. Am J Respir Crit Care Med. 2025;211(7):1156-1164. doi:10.1164/rccm.202411-2165CI
- Garcia-Marcinkiewicz AG, Kovatsis PG, Hunyady AI, et al. First-attempt success rate of video laryngoscopy in small infants (VISI): a multicentre, randomised controlled trial. Lancet. 2020;396(10266):1905-1913. doi:10.1016/S0140-6736(20)32532-0
- Hagberg CA, Artime CA, Aziz MF, eds. Hagberg and Benumof's Airway Management. 5th ed. Philadelphia, PA: Elsevier; 2023.
- Khanam D, Schoenfeld E, Ginsberg-Peltz J, et al. First-Pass Success of Intubations Using Video Versus Direct Laryngoscopy in Children With Limited Neck Mobility. Pediatr Emerg Care. 2024;40(6):454-458. doi:10.1097/PEC.0000000000003058
- Waheed S, Kapadia NN, Jawed DR, Raheem A, Khan MF. Randomized controlled trial to assess the effectiveness of apnoeic oxygenation in adults using a low-flow or high-flow nasal cannula with head side elevation during endotracheal intubation in the emergency department. BMC Res Notes. 2025 Jul 1;18(1):264. doi: 10.1186/s13104-025-07328-7. Erratum in: BMC Res Notes. 2025 Sep 8;18(1):384. doi: 10.1186/s13104-025-07412-y. PMID: 40598378; PMCID: PMC12219693.
TRANSCRIPT
https://cdn.bfldr.com/D6LGWP8S/as/mr2657n4ckgpz7g3tw37gbx/202511_WSP_Nadkarni_transcript
Please visit: http://www.openpediatrics.org OPENPediatrics™ is an interactive digital learning platform for healthcare clinicians sponsored by Boston Children’s Hospital and in collaboration with the World Federation of Pediatric Intensive and Critical Care Societies. It is designed to promote the exchange of knowledge between healthcare providers around the world caring for critically ill children in all resource settings. The content includes internationally recognized experts teaching the full range of topics on the care of critically ill children. All content is peer-reviewed and open-access thus at no expense to the user. For further information on how to enroll, please email: openpediatrics@childrens.harvard.edu
CITATION
Nadkarni V, Burns JP. Pediatric Intubation Practices: Insights from NEAR4KIDS. 11/2025. OPENPediatrics. Online Podcast. https://soundcloud.com/openpediatrics/pediatric-intubation-practices-insights-from-near4kids-by-v-nadkarni-openpediatrics.
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