Pediatric Intubation: Getting the First Attempt Right with Dr. Josh Nagler

How can we make a high-risk, low-frequency procedure safer for the critically ill child?

Dr. Bob Belfer speaks with pediatric emergency physician and airway educator Dr. Josh Nagler (Boston Children's Hospital) about pediatric tracheal intubation. Drawing on multicenter airway registry data and bedside experience, they explore what improves first-attempt success, what contributes to adverse events, and where the pediatric evidence remains limited.

They discuss preoxygenation, the physiology and practical tradeoffs of apneic oxygenation, and video versus direct laryngoscopy - including how a shared screen can support real-time coaching. Dr. Nagler offers practical guidance on stylets, patient positioning, and adapting the setup for infants versus adolescents. They also examine the NEAR4PEM pre-intubation checklist, preparation for peri-intubation hypotension, and the emerging potential of artificial intelligence to identify difficult airways and recognize anatomic landmarks.

Finally, they tackle a challenging question: who should make the first intubation attempt? The conversation explores how to balance patient safety with the need to train clinicians who may one day manage a pediatric airway without immediate specialist support.

Learn more and register for the CHOP/Boston Children's Pediatric Emergency Medicine Conference here.

Studies and resources discussed

Miller KA, Dechnik A, Miller AF, et al. Video-assisted laryngoscopy for pediatric tracheal intubation in the emergency department: a multicenter study of clinical outcomes. Ann Emerg Med. 2023;81(2):113-122.

Miller KA, Prieto MM, Wing R, et al. Development of a paediatric airway management checklist for the emergency department: a modified Delphi approach. Emerg Med J. 2023;40(4):287-292.

National Emergency Airway Registry for Pediatric Emergency Medicine (NEAR4PEM): multicenter airway research, quality improvement, and the pre-intubation checklist.

National Emergency Airway Registry for Children (NEAR4KIDS): pediatric airway safety research and intubation safety resources.

Gawande A. The Checklist Manifesto: How to Get Things Right.

About the guest

Dr. Josh Nagler is a pediatric emergency physician at Boston Children’s Hospital and an Associate Professor of Pediatrics and Emergency Medicine at Harvard Medical School. His research and teaching focus on pediatric airway management, video-assisted laryngoscopy, procedural coaching, and medical education.

About the podcast

The PEM Podcast features thoughtful conversations, practical teaching, and the people and ideas shaping pediatric emergency medicine. It is hosted by Dr. Bob Belfer and is part of HipPEMcrates, an independent pediatric emergency medicine education platform.

Visit HipPEMcrates.com for pediatric emergency medicine articles, literature reviews, clinical pearls, and educational resources.