Nasotracheal Intubation with Videolaryngoscopy versus Direct Laryngoscopy in Infants (NasoVISI) Trial

Annery Garcia-Marcinkiewicz, MD, MSCEAnnery Garcia-Marcinkiewicz, MD, MSCE
Assistant Professor of Anesthesiology & Critical Care, Children’s Hospital of Philadelphia

Dr. Garcia-Marcinkiewicz’s project is entitled: “Nasotracheal Intubation with Videolaryngoscopy versus Direct Laryngoscopy in Infants (NasoVISI) Trial

Background: More than 32,000 infants undergo congenital heart surgery in the United States annually1, with approximately 50% of these patients requiring nasotracheal intubation (NTI). Direct laryngoscopy (DL) is the current standard of care for initial NTI attempts in these patients. Small infants are particularly vulnerable during tracheal intubation because of their rapid rate of oxygen desaturation. Securing the tracheal tube quickly and on the first attempt is the best practice to minimize complications. Our team established a multicenter registry to improve the quality of airway management in children with challenging airways and discovered that multiple tracheal intubation attempts are a key risk factor for severe adverse events such as cardiac arrest, laryngospasm and severe hypoxemia.2 Additionally, our most recent multicenter trial comparing Videolaryngoscopy (VL) to DL in infants found that VL improves first attempt success rate and reduces severe complications when used for orotracheal intubation in infants with normal airways.3 Infants presenting for cardiac surgery often have NTI performed. The short apnea tolerance time in infants, particularly those with cardiovascular anomalies, creates a critical time-pressure to intubate. NTI with DL is the most common clinical practice in infants presenting for cardiac surgery, but often requires additional maneuvers such as the use of Magill forceps or external laryngeal manipulation, all which can contribute to prolonged intubation time and complications. With DL, the supervising clinician is blind to what the trainee sees which makes effective guidance and instrumentation difficult. Observational studies in adults suggest that the use of VL can provide higher NTI success rates and shorter intubation time compared to DL.4 VL improves trainee coaching during tracheal intubation, and the shared view reassures the supervising clinician that the tracheal tube is being placed properly.5 This is highly desirable in vulnerable cardiac infants. There is currently no published data on whether VL is more effective than DL at improving first-attempt NTI success rates and reducing complications in infants. We hypothesize that reducing multiple attempts will enhance the safety of NTI in this vulnerable population.

Aims: This proposal seeks to reduce complications by reducing the number of NTI attempts. We hypothesize that in infants presenting for cardiothoracic procedures requiring NTI, VL as the first attempted device will be associated with increased first-attempt success rate, reduce the number of tracheal intubation attempts, and reduce tracheal intubation-related complications, specifically intubation-associated hypoxemia. Reducing the number of attempts will enhance the safety of airway management in infants presenting for cardiac procedures and is well aligned with the mission of the Anesthesia Patient Safety Foundation.

Implications: Tracheal intubation is a high-risk procedure in infants because of their unique anatomy, high oxygen consumption, and smaller edema prone airways all leading to very limited apnea tolerance, particularly in infants with cardiovascular anomalies. Hypoxemia and multiple attempts are important targets to enhance safety. Infants with cardiovascular anomalies are an extremely high-risk group due to their very limited reserves. Our proposed project would potentially lead to the reduction of multiple NTI attempts, consequent hypoxemia, and associated complications in these infants.


  1. The Society of Thoracic Surgeons. Congenital Heart Surgery Database, table 7 neo infant. Published 2020. Accessed February 17, 2022.
  2. Fiadjoe JE, Nishisaki A, Jagannathan N, et al. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 2016;4(1):37-48.
  3. 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.
  4. Jiang J, Ma DX, Li B, Wu AS, Xue FS. Videolaryngoscopy versus direct laryngoscopy for nasotracheal intubation: A systematic review and meta-analysis of randomised controlled trials. J Clin Anesth. 2019;52:6-16.
  5. Volz S, Stevens TP, Dadiz R. A randomized controlled trial: does coaching using video during direct laryngoscopy improve residents’ success in neonatal intubations? J Perinatol. 2018;38(8):1074-1080.

Funding: $149,119 (January 1, 2023-December 31, 2024). The grant was designated as the APSF/ American Society of Anesthesiologists (ASA) President’s Research Award.