Impact of Difficult Laryngoscopy on First‐Pass Success and Adverse Events in Pediatric Emergency Department Intubations

BACKGROUND: Airway management in the Emergency Department (ED) can be challenging, particularly in children. Difficult laryngoscopy reduces first-pass success and increases complications, but pediatric ED data remain limited. METHODS: We conducted a prospective, observational study of pediatric intubations recorded in the Australian and New Zealand Emergency Department Airway Registry (ANZEDAR) between 2012 and 2025, including 25 Pediatric Research in Emergency Departments International Collaborative (PREDICT) sites. The primary outcome was the incidence of difficult laryngoscopy. Secondary outcomes were the impact of difficult laryngoscopy on First-Pass Success (FPS) and adverse events. The main exposure variable was laryngoscopic grade, defined as difficult when a Cormack-Lehane Grade 3 or 4 view was encountered on the first attempt. Patient, procedural, and operator characteristics were assessed as potential confounders. RESULTS: Of 946 pediatric ED intubations recorded across 55 sites (including 25 PREDICT pediatric sites) between 2012 and 2025, 865 were included in the analysis after exclusion of cases with missing laryngoscopic grade. The median age was 3.5 years. Difficult laryngoscopy (Cormack-Lehane grade 3-4) was observed in 65 cases (7.5%). FPS was significantly lower in patients with a difficult view compared with those with a non-difficult view (41.5% vs. 87.9%; OR 0.10, 95% CI 0.06-0.17). Adverse events were more frequent in the difficult-view group, including hypoxaemia (38.5% vs. 11.5%; OR 4.81, 95% CI 2.79-8.29) and esophageal intubation (15.4% vs. 1.3%; OR 14.36, 95% CI 5.73-35.98). CONCLUSION: Difficult laryngoscopy in pediatric ED intubations is relatively infrequent but associated with reduced FPS and increased complications. These findings emphasize the importance of ongoing quality improvement and may help inform training and escalation strategies. Continued registry participation is valuable to capture these low-frequency events and better understand their consequences.