key: cord-0956936-izd2wscg authors: Saito, Tomoyuki; Tacuchi, Asuka; Asai, Takashi title: Videolaryngoscopy for tracheal intubation in patients with COVID-19 date: 2020-06-11 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.06.002 sha: 560565f76e6c574a66a48d5ed165a944cd5a61a9 doc_id: 956936 cord_uid: izd2wscg nan recommendations 2, 5 recommend use of a videolaryngoscope for the initial attempt at tracheal intubation to minimise the time required to intubate the trachea. Different videolaryngoscopes might perform differently in this setting and work. 6, 7 Requirements for a suitable videolaryngoscope include a high success rate of tracheal intubation even in patients with a difficult airway, intubation time is short, an introducer (e.g. stylet or gum elastic bougie) is not required, and the device can be disposed of or appropriately disinfected after use. Available videolaryngoscopes with a tube guide that satisfy these requirements include the Airtraq ® (Prodol, Vizcaya, Spain), Airwayscope ® (Hoya, Tokyo, Japan), and Kingvison ® (Ambu, Copenhagen, Denmark),. An additional advantage of these videolaryngoscopes is that there is no need to insert a tracheal tube stylet, such that a breathing system filter can be connected to the tracheal tube before intubation, thus minimizing the spread of viral particles (Fig 1) . To determine whether these videolarygoscopes are no less effective than other types of laryngoscopes, we carried out a small randomised simulation trial. Eight anaesthetists with more than three years of clinical experience provided written informed consent to participate. The study incuded the following five laryngoscopes: Airtraq ® AVANT (with a size 3 blade, without a videomonitor attached), Airwayscope ® S-100 (with the standard P blade), with size 3 MAC blade), and Macintosh laryngoscope (Penlon, Oxford, UK, with blade 3). To simulate tracheal intubation in a patient with COVID-19, we used an intubation simulator manikin (TruCorp AirSim ® , TruCorp Ltd, Belfast, Northern Ireland) with an aerosol box ® (Minowa Co., Osaka, Japan) placed over the manikin head (Fig 1) . Each participant had previously performed more than 20 patient intubations with each device. They ten received a demonstration of the five laryngoscopes by one of the investigators, and then practiced at least 10 times for each device on a manikin without wearing PPE. In a computer-generated Friedman's two-way analysis of variance was used to compare intubation time, and if P>0.05, 95% confidence intervals for paired median difference between a videolaryngoscope and a Macintosh laryngoscope were calculated. A sample size of 8 was calculated based on an expectation that intubation time is faster for the Airwayscope ® than for the Macintosh laryngoscope on 90% of occasions (as a cross-over design), with a power of 0.8, and P = 0.05. Statistical analysis was performed by using SPSS version 24 (Armonk, NY, US), with manual calculations for the 95% confidence intervals for the median differences. 8 Tracheal intubation was successful except for one attempt with the Airtraq ® . Intubation time was shorter for the Airwayscope ® than for the Macintosh laryngoscope (median difference [95% CI for paired median difference]: -8 [-13, -3] s), and shorter for the McGrath ® than for the Macintosh laryngoscope (-7 [-12, -3] s) ( Table 1 ). Using simulating of tracheal intubation in a patient with COVID-19 disease, the Airwayscope ® and McGrath ® laryngoscopes were more effective than the other laryngoscopes. Whilst the Airtraq ® is appealing as a single-use device, wearing goggles and a face shield and using the box made it difficult to see the glottis through the eyepiece of the device. Therefore, when this device is to be used a camera monitor needs to be attached to the eyepiece. The Airwayscope ® , which has been shown to be effective with a difficult airway, 9 can be disinfected after use by immersing the whole device into disinfectant solution. The blade of the Kingvison ® is disposable, but its display cannot be immersed to liquid and thus can only be disinfected by an alcohol wipe. In conclusion, our simulation study indicates that different videolaryngoscopes perform differently depending on the circumstance. Despite the small numbers, the Airwayscope ® provided shorter intubation times compared with other laryngoscopes for tracheal intubation in simulation of patients with COVID-19. TA is an editor of the British Journal of Anaesthesia; the other authors have no conflict of interest. Outbreak of a new coronavirus: what anaesthetists should know Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations Protects healthcare providers during endotracheal intubation Barrier enclosure during endotracheal intubation Consensus guidelines for managing the airway in patients with COVID-19 Evaluation of Six Videolaryngoscopes in 720 Patients With a Simulated Difficult Airway: A Multicentre Randomized Controlled Trial Videolaryngoscopes: do they truly have roles in difficult airways? Medians and their differences Statistics with confidence Use of the Pentax-AWS in 293 patients with difficult airways We thank the staff of the Department of Ananesthesiology, Dokkyo Medical University Saitama Medical Centre, for their participation.