Re-evaluating pediatric laryngoscope blade size recommendations: Comparable intubation performance across blade sizes in pediatric manikin models

Background: Pediatric airway management traditionally emphasizes strict adherence to age-based laryngoscope blade size recommendations, despite limited empirical validation. Objectives: To evaluate whether intubation performance varies across a range of blade sizes, and whether a Macintosh 2 blade performs comparably across multiple pediatric age groups in a simulation setting. Methods: We conducted a randomized crossover simulation study using three pediatric airway manikins (neonate, infant, and child age groups). Emergency medicine residents and faculty physicians performed intubations using multiple laryngoscope blade types and sizes, including standard and nonstandard options. Primary outcomes were intubation time and first-attempt success. Secondary outcomes included complications and operator-rated ease of glottic view and tube passage. Between-blade differences were estimated with 95% confidence intervals. Results: Across manikin sizes and blade types, intubation times were short and first-attempt success rates exceeded 98% in most conditions. Performance remained consistent even with blade sizes outside conventional age-based recommendations. Between-blade differences in intubation time were small, and complication rates were low across conditions. The Macintosh 2 blade performed comparably across all manikin sizes, with similar intubation times, high success rates, and favorable ease ratings. Conclusions: Intubation performance in pediatric manikin models was similar across a wide range of blade sizes. These hypothesis-generating findings warrant prospective clinical evaluation of simplified blade selection strategies for pediatric intubation.