A Camera on the Breathing Tube: How a Small Screen Is Helping Doctors Help Newborns Breathe

What a 2025 review of nine studies found about video-guided intubation in babies

When a newborn needs help breathing, doctors sometimes place a small tube into the windpipe — a procedure called intubation. A 2025 review that combined nine studies of more than a thousand newborns found that doing this with a tiny camera on the end of the instrument, so the whole team can see the airway on a screen, helped doctors succeed on the very first try more often than the traditional method of looking directly with the eye. The camera helped most for less-experienced doctors and in the neonatal intensive care unit, and it was linked to less injury to the delicate tissues of the airway.

Why getting it right the first time matters so much

Placing a breathing tube in a newborn is one of the hardest hands-on skills in all of medicine, and the reason is simple: babies are tiny. A newborn's mouth is small, the tongue and other structures are relatively large, the opening to the windpipe sits high and far forward, and there are often secretions in the way [1]. Because of this, even skilled clinicians can struggle to see clearly. Records from a large network of hospitals show that a meaningful share of newborn intubations still take three or more tries, most often in the smallest and most fragile babies [2].

Those extra attempts are not harmless. Each additional try is linked to a several-times-higher chance of the baby's oxygen dropping, the heart rate slowing, or the airway being bruised during the procedure [3]. That is why "first-attempt success" — getting the tube in correctly on the first try — is treated by neonatal teams not as a bragging point but as a genuine safety goal. Anything that reliably raises it is worth taking seriously.

It helps to picture what the doctor is actually facing. In an adult, the path from the mouth to the windpipe is relatively roomy and forgiving. In a newborn — sometimes one who weighs less than a pound — the same landmarks are packed into a space smaller than an adult's fingertip, and the tissues are soft and easily bumped. The doctor has only seconds, because a baby who needs a breathing tube usually is not breathing well on their own, so the clock is always running. Doing all of this while bent over, trying to line up a direct line of sight with one eye, is genuinely hard even for someone who has done it many times. That difficulty is the whole reason researchers have spent years looking for tools and techniques that make the airway easier to see.

How doctors used to face this problem

For decades, the standard way to intubate a newborn was direct laryngoscopy: the doctor holds a lighted blade in the mouth and looks straight down toward the windpipe with their own eye, lining up the view by hand. Learning it meant practising on real babies, over and over, until the movement became second nature [4]. But that path has grown harder. Newer, gentler ways of supporting breathing mean fewer babies need intubation in calm, planned circumstances, so trainees get fewer chances to practise — and the intubations that remain tend to be the urgent, high-pressure ones. In other words, doctors are being asked to master a very difficult skill with fewer opportunities to rehearse it [5].

Video laryngoscopy was designed to change that. Instead of the doctor's eye being the only thing that sees the airway, a small camera near the tip of the blade sends a magnified picture to a screen. Suddenly the trainee, the supervisor, and the rest of the team can all see the same view at the same moment, and a teacher can guide the trainee's hands in real time rather than guessing what went wrong afterward. Early studies of this idea focused on teaching and found that when the supervisor could watch the screen, trainees did better [4], [6]. But other real-world reports were less clear-cut, and for years the medical community lacked a confident answer [7]. Two more recent studies — a large one from Ireland showing a clear benefit for urgent newborn intubations [8], and an international one comparing the two methods head to head [9] — finally gave researchers enough good data to add everything up.

What the 2025 review found

The review by Li and colleagues gathered nine carefully conducted studies, together covering 1,059 newborn intubations, half done with the camera and half the traditional way [10]. Pooling them, the camera method raised the chance of success on the first try by about 21% overall [10]. The benefit was even bigger in the two situations you might expect: in the neonatal intensive care unit, and when the person doing the procedure was less experienced [10]. Put plainly, the screen helped most exactly where extra help was most needed — for learners and in demanding settings.

It is worth being clear about what the camera did not change, because honesty about the limits is part of the story. It did not make the procedure noticeably faster, and it did not clearly reduce the total number of tries once you counted everything [10]. The chances of the baby's oxygen dropping or heart rate slowing during the procedure were about the same with either method — reassuring, because it means adding the camera did not create new problems [10]. The one extra advantage was less injury to the airway tissues, which makes sense: when you can see better, you poke around blindly less. The researchers were careful to say this particular finding, while encouraging, still needs more study before it can be called certain [10].

One more point helps put the results in perspective. When researchers combine many studies, they weigh how trustworthy the combined answer is, not just what it says. Here, the studies were mostly small, done at single hospitals, and — because you obviously cannot hide from a doctor which instrument they are holding — they could not be run in the "blinded" way that makes a study most airtight [10]. The research team used an additional statistical check designed for exactly this situation, and it confirmed that the improvement in first-try success is a real effect rather than a fluke of chance [10]. What is less certain is the precise size of the benefit, which is why the honest summary is "the camera clearly helps, especially for learners, but we are still learning by how much." For a family, the reassuring part is that this is a technology being adopted thoughtfully and studied carefully, not rushed in on a hunch.

What this means for families and their baby's care

If your baby needs a breathing tube, this research offers a quietly hopeful message: the tools and teaching around this difficult procedure are improving, and one of those improvements — a camera that lets the whole team see the airway — genuinely helps doctors get it right the first time, especially in the intensive care unit [10]. If you see a small screen being used during the procedure, it is not a sign that something is wrong; it is a sign the team is using a clear, shared view to work as safely as possible. You are always welcome to ask the team what equipment they use and why.

At the same time, it is fair to know that video laryngoscopy is not yet the official standard everywhere. The main teaching program for newborn resuscitation still centres on the traditional method [11], and the special cameras and blades cost more, which affects how quickly hospitals can adopt them [10]. Different units will be at different stages, and skilled clinicians can still do beautifully with the traditional approach. The evidence here is strong about the direction — the camera helps first-try success — but researchers are honest that they cannot yet pin down the exact size of every benefit, partly because the individual studies were mostly small and done at single hospitals [10], [12].

What researchers are working on next

The clearest next step is bigger, better studies — especially in the tiniest, most premature babies in the delivery room, where a first-try success matters most and where today's evidence rests on just one or two studies [8]. Researchers also want future studies to record the outcomes families care about most, such as avoiding injury and dangerous drops in oxygen, rather than only counting tries [10]. And there is a practical question hospitals must weigh: the cameras cost more, so systems have to balance that price against the real value of getting the tube in safely on the first attempt [3]. None of this diminishes the encouraging bottom line. A simple idea — let everyone see the airway on a screen — is helping doctors, especially those still learning, care for newborns a little more safely than before. For families, the takeaway is not that they need to request a particular device, but that the field is steadily replacing guesswork with a clearer view, and that the people caring for their baby are drawing on the best current evidence to make an already difficult moment as safe as it can be.

References

  1. Sawyer T, Yamada N, Umoren R. The difficult neonatal airway. Semin Fetal Neonatal Med. 2023;28(5):101484. doi:10.1016/j.siny.2023.101484 ↩
  2. Sawyer T, Foglia EE, Ades A, et al. Incidence, impact and indicators of difficult intubations in the neonatal intensive care unit: a report from the National Emergency Airway Registry for Neonates. Arch Dis Child Fetal Neonatal Ed. 2019;104(5):F461–F466. doi:10.1136/archdischild-2018-316336 ↩
  3. Singh N, Sawyer T, Johnston LC, et al. Impact of multiple intubation attempts on adverse tracheal intubation associated events in neonates: a report from the NEAR4NEOS. J Perinatol. 2022;42(9):1221–1227. doi:10.1038/s41372-022-01484-5 ↩
  4. O'Shea JE, Thio M, Kamlin CO, et al. Videolaryngoscopy to teach neonatal intubation: a randomized trial. Pediatrics. 2015;136(5):912–919. doi:10.1542/peds.2015-1028 ↩
  5. Lingappan K, Neveln N, Arnold JL, Fernandes CJ, Pammi M. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in neonates. Cochrane Database Syst Rev. 2023;5(5):CD009975. doi:10.1002/14651858.CD009975.pub4 ↩
  6. Moussa A, Luangxay Y, Tremblay S, et al. Videolaryngoscope for teaching neonatal endotracheal intubation: a randomized controlled trial. Pediatrics. 2016;137(3):e20152156. doi:10.1542/peds.2015-2156 ↩
  7. Moussa A, Sawyer T, Puia-Dumitrescu M, et al. Does videolaryngoscopy improve tracheal intubation first attempt success in the NICUs? A report from the NEAR4NEOS. J Perinatol. 2022;42(9):1210–1215. doi:10.1038/s41372-022-01472-9 ↩
  8. Geraghty LE, Dunne EA, Ní Chathasaigh CM, et al. Video versus direct laryngoscopy for urgent intubation of newborn infants. N Engl J Med. 2024;390(20):1885–1894. doi:10.1056/NEJMoa2402785 ↩
  9. Riva T, Engelhardt T, Basciani R, et al. Direct versus video laryngoscopy with standard blades for neonatal and infant tracheal intubation with supplemental oxygen: a multicentre, non-inferiority, randomised controlled trial. Lancet Child Adolesc Health. 2023;7(2):101–111. doi:10.1016/S2352-4642(22)00313-300313-3) ↩
  10. Li X, Zhang X, Chen D, Yu C, Jiang X. Video vs. direct laryngoscopy for tracheal intubation in neonates: a meta-analysis. Front Pediatr. 2025;13:1674255. doi:10.3389/fped.2025.1674255 ↩
  11. Weiner GM, ed. Textbook of Neonatal Resuscitation. 8th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2021. ↩
  12. Prekker ME, Driver BE, Trent SA, et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med. 2023;389(5):418–429. doi:10.1056/NEJMoa2301601 ↩