Abstract
Difficult airway management remains a major challenge for paediatric anaesthesiologists. Our aim is to visualise the research hotspots of tracheal intubation for children using bibliometric analysis and clarify the development status of this research field. English articles on pediatric intubation (2009–2025, Web of Science) were analyzed. Only original and review studies included. Publication trends, countries, authors, journals, keywords, and citations were statistically analyzed and visualized. The study results showed that a total of 752 eligible articles were included, and the annual number of publications showed a fluctuating increase, reaching a peak of 64 in 2023. The United States ranked first in both the number of publications (265) and citations (5,935). The journal Pediatric Anesthesia had the largest number of publications (58) and also the highest local citations (13,878). The most cited author globally was Silbergleit (468 citations), and the author with the most publications was Nishisaki (27 articles). The institution with the most publications was the University of Pennsylvania. The top three high-frequency keywords were children (329 times, 17%), endotracheal intubation (183 times, 9%) and tracheal intubation (125 times, 6%), and the core research hotspots were intubation efficacy, safety and airway difficulties. Study analyzes 752 pediatric intubation articles (2009–2025), showing growing interest, peak in 2023. U.S. leads; China productive but less recognized. Focus on anesthesia, critical care; Nishisaki prominent. Shift from basic to personalized techniques, emphasizing safety, difficult airways. Lacks Global South input. Highlights trends, guides clinical priorities, informs research.
KEYWORDS: Airway management, bibliometrics, child, endotracheal intubation, knowledge graph
Background
Pediatric tracheal intubation is a core procedure in pediatric anesthesia and emergency airway management. Due to children’s distinct anatomical and physiological features, such as a large head and narrow pharynx, the procedure carries higher technical demands and greater risks than in adults.[1] Inappropriate intubation depth can lead to complications such as endobronchial intubation and hypoxemia,[2] and difficult airways remain a major challenge.[3]
With the expansion of pediatric anesthesia practice, research in this area has grown substantially.[1] While studies have addressed device optimization, depth measurement, and complication prevention,[4,5] there is a lack of systematic analysis of global trends, core institutions, and research hotspots, making it difficult to grasp the field’s overall development.
Bibliometrics applies quantitative methods to analyze literature, revealing a research field’s structure and evolution.[6] Combined with knowledge graphs, it can visually display core elements such as authors, institutions, and keywords.[7] Although used in other medical fields, it has not been systematically applied to pediatric tracheal intubation research.[8,9]
Therefore, this study employs bibliometric methods using the bibliometrix package in R to analyze relevant literature from the Web of Science core database. It aims to clarify annual trends, regional/institutional distributions, and core authors, identify key journals and highly cited studies, visualize research hotspots and thematic evolution, and provide references to guide future high-quality research.
Materials and Methods
Data source
The literature data were retrieved from the Science Citation Index Expanded within the Web of Science core database. The search strategy was developed through the following process: (1) Core keywords were determined based on the research topic – “Endotracheal intubation” (target technique) and “children” (target population, including synonyms such as “preschool children” and “hospitalized children”); (2) The Web of Science thesaurus was consulted to confirm standard subject terms, avoiding omissions due to nonstandard terminology; (3) multiple search combinations (such as [TS = (“Tracheal intubation”)] AND [TS = (“Children”)]) were tested and the strategy adjusted according to the test results (e.g., adding “Preschool Children” to include younger children); (4) a librarian specializing in medical literature retrieval was invited to review the strategy, ensuring its comprehensiveness and accuracy.
We employed a “test-evaluate-optimize” iterative approach to ensure the search strategy achieved an optimal balance between recall and precision. Before the formal retrieval, we conducted three preliminary tests: Preliminary small-scale search: A trial search was performed using core keywords in the target database to assess the relevance of the initial results. Precision test: Fifty search results were randomly sampled and independently reviewed by two researchers for relevance to calculate the initial precision rate. Recall test: Ten known relevant articles were selected to verify whether they could be effectively retrieved by the search strategy.
Based on the results of these preliminary tests, we conducted three rounds of optimization: Round 1: Added domain-specific terms and optimized Boolean logic. Round 2: Supplemented synonyms and broader terms, and adjusted proximity operators. Round 3: Added time limits and document type filters.
The final retrieval formula was (TS = [“Endotracheal intubation”]) AND (TS = [“Preschool Children” OR “children” OR “Hospitalized Children” OR “School-age Children”]). The retrieval conditions were as follows: (1) language – English; (2) literature type – original research articles (“Article”) or review articles (“Review Article”); and (3) publication period – from 2009 (the first year when relevant studies appeared in the Web of Science database, confirmed by testing the 2000–2008 period, from which no eligible studies were retrieved) to 17 March 2025. The search results were exported in “Full Record and Cited References” text format, including information such as the study title, author, institution, country, keywords, abstract, and citations.
Inclusion and exclusion criteria
This study adhered to the RAMIBS guidelines to ensure transparency and reproducibility.[10]
Inclusion criteria
Focus on pediatric tracheal intubation (technology, efficacy, safety, complications, or airway management); original or review articles; English language; indexed in Web of Science SCIE; published between 2009 and March 17, 2025.
Exclusion criteria
Duplicate records; studies with incomplete core information; content unrelated to pediatric tracheal intubation; and nonresearch publications (e.g., conference abstracts, letters, editorials, and case reports).
Two researchers independently screened titles and abstracts. Disagreements were resolved by a third researcher. Interrater reliability was high (Kappa = 0.87; intraclass correlation coefficient = 0.85, 95% confidence interval: 0.82–0.91).
Data processing and analysis
H-index, Citation Burst, and Theme Evolution were selected based on the study’s specific aims, data characteristics, evaluation needs, and RAMIBS guidelines. This combination assesses academic impact, detects research fronts, and analyzes thematic evolution, thereby comprehensively revealing the knowledge structure and trends in the field, consistent with RAMIBS principles on multi-dimensional integration and dynamic analysis.
Data were processed in R 4.4.1 using the bibliometrix package. The workflow included: (1) converting records; (2) removing duplicates and incomplete entries; (3) cross-checking a 10% sample; (4) calculating standard bibliometric indicators; and (5) generating visualizations (collaboration networks, keyword clouds, thematic evolution, and citation bursts) to interpret patterns and trends.[11]
The three visualization techniques – networkPlot, wordcloud, and themeEvolution – were chosen for their analytical suitability. They intuitively present the domain’s structure, hotspots, and temporal evolution: networkPlot maps relationships and centrality, wordcloud highlights term frequency, and themeEvolution traces thematic changes over time.
Results
Global annual publication
A total of 794 relevant articles were retrieved and screened from the Web of Science database, and 42 articles were excluded after title and abstract screening (including 15 duplicate articles, 12 non-research-type articles, and 15 articles unrelated to pediatric tracheal intubation), resulting in 752 eligible articles. The first article on pediatric tracheal intubation in the Web of Science database was published in 2009, and the annual number of publications showed a fluctuating increase across different time periods [Figure 1]: 2009–2013 (annual average: 31), 2014–2019 (annual average: 46), and 2020–2025 (annual average: 49), with a peak of 64 in 2023.
Figure 1.
The publication of relevant literature.
Regional publication and citation analysis
A total of 44 countries/regions contributed to the research field of pediatric tracheal intubation. The top 10 countries in terms of publication quantity are shown in Table 1. The United States ranked first with 265 publications (33.4% of the total), followed by China (87 publications, 11.0%) and Germany (32 publications, 4.0%). The United States had a significant lead in publication quantity, with more than three times the number of publications of China.
Table 1.
The top ten countries in terms of the number of related publications.
| Rank | Country | Number of publications | Proportion (%) | SCP number | SCP proportion (%) | MCP number | MCP proportion (%) | TC | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | United States | 265 | 33.38 | 226 | 85.3 | 39 | 14.7 | 5935 | ||||||||
| 2 | China | 87 | 10.96 | 83 | 95.4 | 4 | 4.6 | 652 | ||||||||
| 3 | Germany | 32 | 4.03 | 29 | 90.6 | 3 | 9.4 | 786 | ||||||||
| 4 | Turkey | 32 | 4.03 | 32 | 100 | 0 | 0 | 428 | ||||||||
| 5 | Australia | 28 | 3.53 | 18 | 64.3 | 10 | 35.7 | 395 | ||||||||
| 6 | India | 28 | 3.53 | 27 | 96.4 | 1 | 3.6 | 352 | ||||||||
| 7 | United Kingdom | 28 | 3.53 | 20 | 71.4 | 8 | 28.6 | 289 | ||||||||
| 8 | Korea | 25 | 3.15 | 24 | 96 | 1 | 4 | 246 | ||||||||
| 9 | Canada | 22 | 2.77 | 12 | 54.5 | 10 | 45.5 | 198 | ||||||||
| 10 | Japan | 20 | 2.52 | 16 | 80 | 4 | 20 | 185 |
SCP=Single-Country Publications, MCP=Multi-Country Publications, TC=Total citations
In terms of citations [Figure 2a], the United States also ranked first with 5935 total citations (average citations per paper: 22.4), followed by Germany (786 total citations, average citations per paper: 24.6) and China (742 total citations, average citations per paper: 8.5). China ranked second in publication quantity but third in total citations, and its average citations per paper were significantly lower than those of the United States and Germany.
Figure 2.
The publication and citation of countries. (a) The top ten countries cited in the relevant literature; (b) single-country publication and multi-country publication publications; (c) national distribution map.
The analysis of single-country publications (SCPs) and multicountry publications (MCPs) is presented in Figure 2b. The United States, China, and Italy had high SCP proportions (82.3%, 90.8%, and 84.4%, respectively), indicating that these countries mainly conduct independent research. By contrast, Canada had the highest MCP proportion (33.3%).
Figure 2c, a global publication distribution map, visually displays the geographic spread of pediatric tracheal intubation research. A gradient color scale represents each country’s output: darker colors indicate higher publication counts. The map shows North America, led by the United States, with the darkest shade, reflecting its dominant output. East Asia (centered on China) and Western Europe (including Germany, Italy, and the UK) also appear as darker regions, forming significant research clusters. In contrast, most areas in Africa, Central Asia, and Southeast Asia are lightly colored, indicating minimal to no related publications.
Journal publication and citation analysis
A total of 217 journals published articles on pediatric tracheal intubation. The top 10 journals in terms of local citations are shown in Figure 3a. Pediatric Anesthesia had the highest local citations (13,878), followed by Pediatric Critical Care Medicine (8765) and Resuscitation (6542). Pediatric Anesthesia also had the largest number of publications [58, Figure 3b], accounting for 7.7% of the total.
Figure 3.
Journals published and cited. (a) Citation ranking of each journal; (b) the number of publications in each journal; (c) the ranking of the influence of each journal; (d) the cumulative number of articles published in each journal changes with time; (e) Bradford’s Law analysis results.
In terms of journal influence [Figure 3c], Resuscitation had the highest impact factor (8.7, 2024), followed by Pediatric Critical Care Medicine (7.2, 2024) and Pediatric Anesthesia (5.9, 2024). Most of the top journals had impact factors between 1 and 6, indicating that the field still lacks high-impact publishing channels, and there is room for improvement in the quality of research results.
The cumulative number of publications of the top five journals between 2009 and 2025 [Figure 3d] showed that Pediatric Anesthesia and Pediatric Critical Care Medicine had a rapid increase in publications, and their cumulative numbers by 2025 were 58 and 42, respectively, far higher than those of other journals.
Bradford’s law analysis [Figure 3e] showed that the distribution of journals conformed to Bradford’s law: a small number of core journals published most of the articles (core zone: 3 journals, 128 articles; related zone: 15 journals, 245 articles; scattered zone: 199 journals, 379 articles).
Citation of articles
Figure 4a shows the top 10 most cited articles globally. The top three are by Silbergleit (468 citations), Kapur (322), and Keels (281). Nishisaki is the most cited author within the local dataset [51 citations; Figure 4b].
Figure 4.
Citation of articles. (a) Ranking of the most cited articles in the world; (b) ranking of the most cited articles in the local; (c) the most cited literature in each article; (d) citation network clustering analysis.
The foundational literature most cited by the 752 included articles is presented in Figure 4c. The work by Gausche et al.[12] (JAMA, 2000) ranks first, cited 64 times. This seminal study analyzed outcomes of pediatric out-of-hospital intubation, and its high citation reflects its foundational status for subsequent emergency intubation research. Other frequently cited works focus on pediatric airway anatomy[13] and depth-calculation formulas,[14] underscoring the field’s core topics.
The citation network forms two main clusters associated with Nishisaki and Gausche [Figure 4d]. Citation burst analysis indicates Silbergleit’s study was prominent from 2018 to 2022 (burst strength: 28.3), whereas Nishisaki’s work showed a burst from 2020 to 2024 (burst strength: 22.1), highlighting recent sustained interest in intubation depth and head position.
Institutional publication analysis
A total of 895 institutions have contributed to this field. The top 10 institutions in terms of the number of publications are shown in Figure 5a, with the top 3 being the University of Pennsylvania, the Children’s Hospital of Philadelphia, and Pennsylvania Medicine. The trend in the number of papers issued by the top institutions over time is shown in Figure 5b. The number of papers issued by each institution has shown a steady upward trend, with the number of papers issued by the University of Pennsylvania increasing rapidly and at a much higher rate than that of other institutions.
Figure 5.
Institutional issuance. (a) Ranking the number of institutional publications; (b) changes in the number of papers issued by agencies over time.
Author publication and influence analysis
A total of 3802 authors have contributed to this field. The top 10 authors in terms of the number of publications are shown in Figure 6a, with the top 3 being Nishisaki (27 articles), Nadkarni (15 articles), and Napolitano (14 articles); in the ranking of local citations, Nishisaki ranked first, with 252 local citations [252, Figure 6b]. This author also ranked first in terms of author influence [H-index: 18, Figure 6c].
Figure 6.
The author’s publication. (a) Ranking of the number of publications; (b) local citation ranking; (c) influence ranking (H index); (d) the change of the author’s volume over time; (e) the country where the author is located and the keywords used in the published article (the left side is the country name, the middle is the author name, and the right side is the keyword name); (f) Lotka’s Law analysis results.
The number of articles published by the top 10 authors in this field between 2009 and 2025 was high [Figure 6d]. The national and institutional distribution of the top 10 authors [Figure 6e] showed that 8 authors were from the United States and were mostly affiliated with the University of Pennsylvania or Pennsylvania Medicine.
Lotka’s law analysis [Figure 6f] showed that the distribution of author publications conformed to Lotka’s law. A small number of core authors published most of the articles (authors with ≥5 publications: 32, 0.8% of the total; articles: 289, 38.4% of the total).
Cooperation network analysis
Author collaboration analysis revealed seven clusters [Figure 7a]. The largest, led by Nishisaki, comprised 15 authors (network density: 0.62) and focuses on intubation depth and airway difficulty.
Figure 7.
Cooperation network analysis. (a) Author cooperation network diagram; (b) institutional cooperation network diagram; (c) national cooperation network diagram.
Institutional collaboration formed nine clusters [Figure 7b]. The largest, led by the University of Pennsylvania and Harvard University, included 23 institutions (density: 0.58), demonstrating mature inter-institutional cooperation in the U.S.
National collaboration showed seven clusters [Figure 7c]. The U.S.-led cluster included 12 countries, such as Canada and the UK (density: 0.45). These stable networks facilitate knowledge sharing and resource integration.
High-frequency keywords and keyword co-occurrence network analysis
Keywords summarize an article’s core information. Statistical analysis of high-frequency keywords reveals the research field’s main focus and hotspots. A treemap [Figure 8a] visualizes keyword frequency, where larger areas indicate higher occurrence.
Figure 8.
High-frequency keywords and topic change analysis. (a) Keyword tree diagram; (b) keyword co-occurrence network; (c) theme evolution diagram.
From 752 articles, 1564 keywords were extracted. The top 10 high-frequency keywords [Figure 8a] are: children (329), endotracheal intubation (183), tracheal intubation (125), pediatric anesthesia (98), difficult airway (87), intubation depth (76), complications (68), mechanical ventilation (62), neonates (59), and emergency (55). These cover the target population, core techniques, clinical scenarios, key issues, and related technologies.
The keyword co-occurrence network [Figure 8b] formed two clusters: Cluster 1 (centered on “children”) includes pediatric anesthesia, difficult airway, and intubation depth, focusing on routine clinical management. Cluster 2 (centered on “neonates”) includes emergency, mechanical ventilation, and complications, focusing on neonatal emergency intubation.
The thematic evolution [Figure 8c] shows three stages: (1) 2009–2013 (initial): basic research on airway anatomy and device selection; (2) 2014–2019 (development): focus on safety and complication prevention; and (3) 2020–2025 (mature): emphasis on personalized and precise management, e.g., ultrasound guidance. This progression aligns with clinical demands for improved safety and efficacy.
Discussion
Research status and regional distribution characteristics
This study analyzed 752 pediatric tracheal intubation articles from the Web of Science core database. Annual publications showed a fluctuating upward trend, peaking in 2023, reflecting growing global focus on pediatric anesthesia safety and the advancement of related technologies.
Regionally, the United States leads in publications and citations, supported by mature collaboration networks.[15] This is attributed to substantial research funding, close integration of clinical practice and research providing rich data, and active international cooperation.[16,17]
China ranks second in publication volume but third in total citations, with a lower average citation count. This likely results from a later research start (around 2015), a prevalence of small-sample single-center studies limiting impact, and publication in lower-impact journals hindering international visibility.[18,19,20] Future efforts should emphasize multicenter cooperation, focus on high-value clinical problems, and enhance research quality and dissemination.
Core research hotspots and clinical implications
Analysis of high-frequency keywords and thematic evolution reveals that core hotspots in pediatric tracheal intubation are efficacy, safety, and airway difficulties, aligning closely with clinical needs.
Intubation efficacy relies on selecting appropriate devices and optimizing techniques, such as using video laryngoscopes for difficult airways[21] or ultrasound for depth guidance.[22] Clinicians should master these methods based on individual patient factors.
Intubation safety primarily concerns accidental extubation, endobronchial intubation, and mucosal injury. To enhance safety, standardize depth measurement, strengthen monitoring (e.g., continuous EtCO2), and train staff in extubation prevention.
Airway difficulties in children stem from anatomical features such as a large head and high larynx. A pre-intubation assessment should identify risk factors (e.g., obesity and congenital anomalies), prepare backup devices, and establish emergency plans.
This study provides a macro-level evidence map for the field. For clinicians, it clarifies the safety baseline in difficult airway management, points toward technical evolution (visualization and personalization), and highlights the need to consider resource limitations and regional differences when applying international experience.
Regional distribution of research and the importance of Global South collaboration
Publication data show that the top 10 publishing countries are predominantly developed nations (e.g., the USA, Germany, and Italy), whereas contributions from the Global South (e.g., Africa, Southeast Asia, and Latin America) are limited; no African country ranks within the top 20. This disparity likely reflects interrelated resource constraints in low- and middle-income countries, including shortages in the trained anesthesia workforce, inadequate clinical and research infrastructure, limited access to appropriate equipment, and insufficient institutional support for data generation and research.[23]
However, children in the Global South face unique intubation challenges, such as a higher incidence of difficult airways due to respiratory infections. The lack of local research hinders the development of context-appropriate management strategies and introduces bias into international guidelines, which often over-rely on data from developed countries.
Therefore, strengthening international collaboration is crucial. Developed countries can share resources through technical training and equipment support. Including Global South populations in multi-center studies would enrich data and improve generalizability. Jointly addressing global challenges, such as preventing intubation-related infections, can advance pediatric health worldwide. International academic organizations should lead in establishing cooperative platforms to promote greater participation from the Global South.
The influence of publishing outlets needs to be enhanced
Journal analysis revealed that a total of 217 journals have published articles on pediatric tracheal intubation. Pediatric Anesthesia had the largest number of publications, accounting for 7.7% of the total, indicating that it is the core journal in this research field. However, the impact factors of most top journals range between 1 and 6, with the highest being Resuscitation (8.7, 2024). This suggests that the field still lacks high-impact publishing channels, and there is room for improvement in the quality of research outcomes.
Limitations of the study
This study has several limitations. First, the literature search was limited to the Web of Science core collection, potentially missing relevant studies in other databases and introducing language or regional bias. Future work should include multiple databases for more comprehensive coverage. Second, only English articles were included, which may exclude quality research in other languages, though English publications still reflect the global research landscape. Third, despite using standardized criteria and cross-checking, some subjectivity remains in the screening and data extraction process. Finally, this study focuses on quantitative bibliometric analysis and does not provide in-depth qualitative assessment of key articles. Future research could combine content analysis to better explore research themes and debates.
Conclusion
This study analyzes 752 pediatric intubation articles (2009–2025), showing rising interest, with a peak in 2023. U.S. leads; China is productive but less recognized. Focus: Paediatric Anaesthesia, Critical Care; Nishisaki is a key figure. Field shifts from basic to personalized techniques, stressing safety, efficacy, and difficult airways, but lacks Global South input, needing more collaboration. Findings highlight trends, guide clinical priorities like ultrasound use, extubation prevention, and inform future studies.
Authors’ contributions
F. Yang and L. Liu equally contributed to the conception and design of the research; Y. N. Li contributed to the design of the research; L. Chen contributed to the acquisition and analysis of the data; L. Y. Li and J. L. Liang contributed to the interpretation of the data; and F. Yang and L. Liu drafted the manuscript. All authors critically revised the manuscript, agree to be fully accountable for ensuring the integrity and accuracy of the work, and read and approved the final manuscript.
Ethics approval and consent to participate
An ethics statement is not applicable because this study is based exclusively on published literature.
Data availability statement
Data are provided within the manuscript.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Hebei Provincial Health Commission Key Scientific Research Plan, Project No.: 20230141.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are provided within the manuscript.