Over a decade ago, we published a review of 83 pediatric endotracheal intubations done in 2009 in the emergency department (ED) of the Aga Khan University Hospital, reporting underuse of rapid sequence intubation (RSI), which entails the use of induction agents or neuromuscular blocking agents, frequent complications, and reliance on anesthesiologists for airway management (1). Since then, measures were implemented to strengthen pediatric airway management, including structured RSI protocols, continuous pediatric emergency faculty coverage, availability of pediatric video laryngoscopes (VLs), and routine simulation-based airway training for trainees and staff. These efforts aimed to standardize practice, improve safety, and develop independent airway competency among emergency physicians (EPs). In a follow-up quality improvement, a prospective review (IRB exemption no. 2022-7491-21794) conducted in 2023-2024, we analyzed 232 intubation cases performed on patients aged 0-18 years in the same ED to evaluate how practice patterns and safety have evolved.

Whereas only 58% of intubations in 2009 involved any pharmacologic assistance (1), in recent years, 96.1% (223/232) of the cases were facilitated with induction agents (ketamine, nalbuphine, and midazolam) and neuromuscular blocking agents (cisatracurium being the most common). This shift toward routine RSI use reflects a stronger institutional and ED commitment to safe airway practice.

In the earlier era, approximately one-third of intubations were performed by anesthesiologists (1). In contrast, the 2023-2024 data show that 88.4% (205/232) of intubations were performed by the EPs, reflecting their growing autonomy and reduced reliance on anesthesiologists for airway management.

In 2009, all intubations used direct laryngoscopy. Our recent data showed the first use of VL in our pediatric ED. VL was used in 26.7% (62/232) and achieved a 67% (42/62) first-attempt success rate. Direct laryngoscopy was used in 75.4% (175/232), with a 49.1% (86/175) first pass success rate, with fewer hypoxia episodes and esophageal intubations. This demonstrates the added value of VL in pediatric airway management.

In 2009, complications included cardiac arrest in 10% of cases and hypoxia in 1% (1). In 2023-2024, despite a larger caseload, the major complication rate, such as that of cardiac arrest, decreased to 6.0% (14/232) of the cases, while minor complications, such as hypoxia, increased to 10.8% (25/232). The decrease in the major complication rate was observed even though a 3.4% (8/232) mortality during intubation was documented due to the prospective design. These findings highlight that better preparedness, enhanced monitoring, and adherence to the standardized protocols have contributed to improved procedural safety.

This letter shows how focused investment in training, technology, and standardized processes could improve pediatric airway outcomes in resource-limited settings. This prospective review shows that the increases in the use of RSI medications, integration of VL, and strengthened provider skills have collectively made airway management safer. Remaining gaps can be addressed through regular simulation-based airway drills, a national pediatric airway registry, and multicenter collaboration to benchmark performance. A shift toward ED-led intubations and the increased use of modern devices make these insights applicable to other low- or middle-income countries seeking to enhance pediatric airway management.