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      Evaluation of the Effect of Intubation Box use on Tracheal Intubation Difficulty with King Vision ® and Truview Videolaryngoscope in Manikin in a Tertiary Care Hospital

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          Abstract

          Background

          The procedures of introducing an airway by intubation are associated with increased risk of aerosolisation of SARS-CoV-2 virus, posing a high risk to the personnel involved. Newer and novel methods such as the intubation box have been developed to increase the safety of healthcare workers during intubation.

          Methods (design)

          In this study, 33 anaesthesiologist and critical care specialists intubated the trachea of the airway manikin (US Laerdal Medical AS™) 4 times using a King Vision ® videolaryngoscope and TRUVIEW PCD™ videolaryngoscope (with and without an intubation box as described by Lai). Intubation time was primary outcome. Secondary outcomes were first-pass intubation success rate, percentage of glottic opening (POGO) score and peak force to maxillary incisors.

          Results

          Intubation time and the number of times a click was heard during tracheal intubation were considerably higher in both groups when an intubation box was used ( Table 1). When comparing the two laryngoscopes, the King Vision ® videolaryngoscope enabled much less time to intubate than did the TRUVIEW laryngoscope, both with and without the intubation box. (P<0.001) In both laryngoscope groups, first-pass successful intubation was higher without the intubation box, although the difference was statistically insignificant. POGO score was not affected by intubation box but a higher score was observed with King Vision ® laryngoscope ( Tables 1, 2).

          Conclusion

          This study indicates that use of an intubation box makes intubation difficult and increases the time needed to perform it. King Vision ® videolaryngoscope results in lesser intubation time and better glottic view as compared to TRUVIEW laryngoscope.

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          Most cited references11

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          Barrier Enclosure during Endotracheal Intubation

          To the Editor: Clinicians with inadequate access to standard personal protective equipment (PPE) have been compelled to improvise protective barrier enclosures for use during endotracheal intubation. We describe one such barrier that is easily fabricated and may help protect clinicians during this procedure. The barrier studied was an “aerosol box,” 1 which consists of a transparent plastic cube designed to cover a patient’s head and that incorporates two circular ports through which the clinician’s hands are passed to perform the airway procedure. The dimensions of the box are provided in the Supplementary Appendix, available with the full text of this letter at NEJM.org. In our simulation (see video), a laryngoscopist, attired in standard PPE, took position at the head of an airway mannequin. To approximate a forceful cough and generate a spread of droplets and aerosols, a small latex balloon containing 10 ml of fluorescent dye was placed in the hypopharynx of the mannequin. The balloon was inflated with compressed oxygen that was run through tubing inside the mannequin until the balloon burst; the explosion of the balloon represented a crude simulation of a cough. We repeated the experiment without and with the aerosol box, and after each simulation, we illuminated the scene with ultraviolet light to visualize the spreading of the dye. With the use of PPE only, dye was found on the laryngoscopist’s gown, gloves, face mask, eye shield, hair, neck, ears, and shoes (Figure 1). Contamination of the floor occurred within approximately 1 m from the head of the bed and also on a monitor located more than 2 m away. When we repeated the experiment with the aerosol box, the simulated cough resulted in contamination of only the inner surface of the box and the laryngoscopist’s gloves and gowned forearms. Examination of the laryngoscopist and the room with ultraviolet light showed no macroscopic contamination outside the box. Our simulation method, although pragmatic, was not validated for the projectile direction, speed, or turbulence of a true cough, nor did it match the particle-size distribution. Droplets were overproduced as compared with aerosols. Our method of detection could not identify very small quantities of material that could be infectious. Nevertheless, we suggest that our ad hoc barrier enclosure provided a modicum of additional protection and could be considered to be an adjunct to standard PPE. A caveat: we found that the box restricted hand movement and would require training before use in the treatment of patients. Operators should be ready to abandon use of the box should airway management prove difficult.
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            The aerosol box for intubation in coronavirus disease 2019 patients: an in‐situ simulation crossover study

            Abstract The coronavirus disease 2019 pandemic has led to the manufacturing of novel devices to protect clinicians from the risk of transmission, including the aerosol box for use during tracheal intubation. We evaluated the impact of two aerosol boxes (an early‐generation box and a latest‐generation box) on intubations in patients with severe coronavirus disease 2019 with an in‐situ simulation crossover study. The simulated process complied with the Safe Airway Society coronavirus disease 2019 airway management guidelines. The primary outcome was intubation time; secondary outcomes included first‐pass success and breaches to personal protective equipment. All intubations were performed by specialist (consultant) anaesthetists and video recorded. Twelve anaesthetists performed 36 intubations. Intubation time with no aerosol box was significantly shorter than with the early‐generation box (median (IQR [range]) 42.9 (32.9–46.9 [30.9–57.6])s vs. 82.1 (45.1–98.3 [30.8–180.0])s p = 0.002) and the latest‐generation box (52.4 (43.1–70.3 [35.7–169.2])s, p = 0.008). No intubations without a box took more than 1 min, whereas 14 (58%) intubations with a box took over 1 min and 4 (17%) took over 2 min (including one failure). Without an aerosol box, all anaesthetists obtained first‐pass success. With the early‐generation and latest‐generation boxes, 9 (75%) and 10 (83%) participants obtained first‐pass success, respectively. One breach of personal protective equipment occurred using the early‐generation box and seven breaches occurred using the latest‐generation box. Aerosol boxes may increase intubation times and therefore expose patients to the risk of hypoxia. They may cause damage to conventional personal protective equipment and therefore place clinicians at risk of infection. Further research is required before these devices can be considered safe for clinical use.
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              Assessment of airway visualization: validation of the percentage of glottic opening (POGO) scale.

              Research defining optimal methods of intubation has been limited by the lack of a validated outcome measure to assess airway visualization. The objective of this study was to develop a reliable scale for the assessment of airway visualization during endotracheal intubation. This prospective study was performed to assess the intra- and interphysician reliabilities of emergency physicians (EPs) for estimating the percentage of glottic opening (POGO) that is visualized during direct laryngoscopy. Using video images of laryngeal views obtained from a commercially available videotape, still slide images were prepared representing glottic openings ranging from 0% to 100%. Five EPs, blinded to study objective, reviewed 25 pairs of airway slides (50 slides total). For each slide, the physicians recorded the POGO and their scores using a modified Cormack-Lehane (MCL) scale, where grade I is a view of the full glottic opening, MCL grade II is a partial view of the glottic opening, and MCL grade III is a view of the epiglottis only. Inter- and intraphysician reliabilities were assessed using the kappa statistic (K) for MCL grade and intraclass correlation coefficient for the POGO scores. For the POGO score, the degree of intrarater reliability was very good, with an intraphysician correlation of 0.85 and an interphysician correlation of 0.74. For the MCL score, the intraphysician concordance had a K of 0.71, and interphysician concordance was also good, with a kappa of 0.59. Both the modified version of the Cormack-Lehane grading classification and the POGO score have good interphysician and intraphysician reliabilities. Because the POGO score can distinguish patients with large and small degrees of partial glottic visibility, it might provide a better outcome for assessing the difference between various intubation techniques.
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                Author and article information

                Journal
                Rom J Anaesth Intensive Care
                Rom J Anaesth Intensive Care
                rjaic
                Romanian Journal of Anaesthesia and Intensive Care
                Sciendo
                2392-7518
                2502-0307
                July 2021
                25 September 2022
                : 28
                : 1
                : 25-28
                Affiliations
                [1 ]Comparative study to evaluate the effect of intubation box on tracheal intubation difficulty with King Vision® and TRUVIEW video laryngoscope in manikin in a tertiary care hospita , India
                Article
                rjaic-2021-0004
                10.2478/rjaic-2021-0004
                9949008
                8f834db6-5866-453d-856d-7f1234f0f7f9
                © 2021 Nazia Nazir, published by Sciendo

                This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

                History
                Page count
                Pages: 4
                Categories
                Original Article

                airway management,anaesthesiologist,intubation,sars-cov-2 pandemic,manikin,laryngoscope

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