Use Of Video Laryngoscopy Research Articles

Airway management practices in COVID ICU during the first and second phases of the pandemic: our experience

Various airway management devices and techniques have been revised and recommended to be used in COVID patients.1 In India, during the first wave (April 2020 to November 2020)2 the intubation strategy included: consultant-led intubation teams, the use of video laryngoscope (VL) and aerosol box (AB).3 During the second wave (April 2021 to June 2021),2 the intubation procedures were modified according to the availability of the resources, manpower, and some experience gained from the first wave.
 Key words: Airway management; COVID-19; Pandemic; Intensive care
 Citation: Nazir N, Saxena A. Airway management practices in COVID ICU during the first and second phases of the pandemic: our experience. . Anaesth. pain intensive care 2021;25(6):834–835;
 DOI: 10.35975/apic.v25i6.1716 

The Use of Video Laryngoscopy Did Not Lead to Greater First-Pass or Overall Success Rates Compared to Direct Laryngoscopy in Pediatric Intubation in a Helicopter Emergency Medical Service

ObjectiveWe hypothesized that video laryngoscopy (VL) would significantly increase the first attempt and final success rates over direct laryngoscopy (DL) in helicopter emergency medical services. MethodsThis was a study of an emergency medical service in the Midwestern United States. Pediatric patients (age < 18 years) transported between January 1, 2010, and July 31, 2016, with an attempted intubation were identified. Demographics (age group and sex), first-pass success (FPS), and total attempts by intubation type were abstracted and compared with a historical control. ResultsFifty-five pediatric patient runs were abstracted (DL: n = 28, VL: n = 27). There were no significant differences between the DL and VL groups based on sex (DL: 54% male, VL: 70% male; P = .200) or age group (P = .239). Analyses of FPS between DL and VL showed no difference (DL: 82.1% success vs. VL: 70.4% success; P = .304). There was no difference for final success rate between DL and VL (DL: 85.7%, VL: 96.3%; P = .172). A significantly larger number of difficult airways were reported in the VL group (37.0%) compared with DL (7.1%, P = .007). ConclusionVL did not improve FPS over DL nor did it improve the final endotracheal intubation success rate over DL. The VL group had more airways reported as being difficult by the flight crew than the DL group.

Emergency Pediatric Intubations in an Urban Children's Hospital Before and After Just-in-Time Training for Video Laryngoscopy.

Objectives: The use of video laryngoscopy (VL) may augment emergency pediatric intubations outside the operating room (OR). Our objective was to describe the proportion of use and complications with VL before and after implementation of a VL just-in-time training (JITT).Study design: This study was a retrospective chart review of pediatric intubations performed outside the OR at a single women and children’s hospital from January 2015 to March 2020. Data were collected on patient age, intubation method, operator characteristics, adverse events, number of attempts, condition leading to intubation, and hospital location. Data were separated into pre-JITT (January 1, 2015 to April 31, 2018) and post-JITT (May 1, 2018 to March 1, 2020) periods. Descriptive statistics were used comparing pre- and post-JITT periods for VL use, and the complications of intubations with multiple attempts (IMAs) and intubations with one or more adverse events (AEs).Results: A total of 231 pediatric patients were intubated during the study period; 154 intubations in the pre-JITT and 77 intubations in the post-JITT periods. Pre- and post-JITT VL use was 17 (11%) and 17 (22%), respectively. With pre-JITT VL, there were four (23%) IMAs and zero (0%) intubation with one or more AE. With post-JITT VL, there were eight (47%) IMAs and one (6%) intubation with one or more AE.Conclusion: The proportion of emergency pediatric intubations using VL increased after the institution of a JITT. There was no significant change in IMAs and AEs. The infrequency of pediatric intubations makes drawing conclusions regarding the impact on IMAs and AEs challenging. JITT may increase VL use for emergency pediatric intubations outside the OR and may be considered for refresher training, especially during the coronavirus disease 2019 (COVID-19) pandemic.

14 Is Coaching Using Video Laryngoscopy Superior to Traditional Method for Improving Pediatric Intubation Skills?

Pediatric intubations are critical procedures that can have significant morbidity or even mortality. Complexity and low frequency make it challenging for trainees to attain procedural competency. In traditional direct laryngoscopy (DL) training, the learner practices intubation on a mannequin while the instructor provides feedback. The use of video laryngoscopy (VL) allows others to have identical views of the airway as the operator and has been shown to improve the acquisition of DL intubation skills.

Use of video laryngoscope in a difficult paediatric cleft palate airway: Rescue or primary airway device?

Use of video laryngoscope in a difficult paediatric cleft palate airway: Rescue or primary airway device?

Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative.

Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department. This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback. We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62-3.76]) (adjusted OR 3.87 [1.13-13.23]) and good Cormack-Lehane views (grades 1-2) (OR 2.71 95% CI [1.74-4.20]) (adjusted OR 7.88 [2.43-25.53]). Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack-Lehane views (grades 1-2) are independently associated with improved first-pass success.

Video laryngoscopy vs. direct laryngoscopy for nasotracheal intubation in oromaxillofacial surgery: a systematic review and meta-analysis of randomized controlled trials.

BackgroundNasotracheal intubation (NTI) is commonly performed in oromaxillofacial surgeries. We did this meta-analysis to ascertain whether use of video laryngoscopy (VL) provided better NTI characteristics as compared to direct laryngoscopy (DL) in patients undergoing oromaxillofacial surgeries.MethodsWe performed a systematic search to identify randomized controlled trials comparing VL with DL for NTI in adults undergoing elective oromaxillofacial surgery. The primary outcome was time to intubation. Secondary outcomes included the first attempt success, overall success, incidence of nasal bleeding, Cormack and Lehane grade, and maneuvers required.ResultsOf the 456 studies identified following a systematic search, 10 were included. Meta-analysis showed a significantly lower time to tracheal intubation favoring VL (mean difference: –9.04, 95% CI [–12.71, –5.36], P < 0.001; I2 = 59%). VL was also associated with a greater first attempt success (relative risk [RR]: 1.10, 95% CI [1.04, 1.16], P = 0.001). Maneuvers to facilitate intubation were less with VL (RR: 0.22, 95% CI [0.10, 0.51], P < 0.001). There was no difference in overall intubation success (RR: 1.04, 95% CI [0.98, 1.10], P = 0.17). The incidence of bleeding did not differ between the DL and VL groups (RR: 0.59, 95% CI [0.32, 1.08], P = 0.09).ConclusionsEvidence as per this meta-analysis suggests VL leads to a shorter time to NTI, a greater first attempt success rate, and reduced need for maneuvers when compared to DL. The present study supports use of VL as a first line device for NTI in oral-maxillofacial surgeries in experienced hands.

Successful airway management with combined use of a McGRATHTM MAC videolaryngoscope and fiberoptic bronchoscope in a patient with congenital tracheal stenosis diagnosed in adulthood

BackgroundMost patients with congenital tracheal stenosis (CTS) develop respiratory symptoms early in life. CTS remaining undiagnosed until adulthood is rare.Case presentationA 51-year-old female was scheduled for cardiovascular surgery. She had undergone laparoscopic surgery 3 years earlier and was found to have a difficult airway. Postoperatively, she was diagnosed with CTS. For the current cardiovascular surgery, combined use of a McGRATHTM MAC videolaryngoscope and fiberoptic bronchoscope allowed sufficient visualization of the glottis and trachea, resulting in successful intubation.ConclusionsCTS patients have a high probability of difficult intubation. Our experience suggests the efficacy of combined use of a videolaryngoscope and fiberoptic bronchoscope for airway management in CTS patients.

Preparation for airway management in Australia and New Zealand ICUs during the COVID -19 pandemic.

BackgroundThis paper aimed to describe the airway practices of intensive care units (ICUs) in Australia and New Zealand specific to patients presenting with COVID-19 and to inform whether consistent clinical practice was achieved. Specific clinical airway guidelines were endorsed in March 2020 by the Australian and New Zealand Intensive Care Society (ANZICS) and College of Intensive Care Medicine (CICM).Methods and findingsProspective, structured questionnaire for all ICU directors in Australia and New Zealand was completed by 69 ICU directors after email invitation from ANZICS. The online questionnaire was accessible for three weeks during September 2020 and analysed by cloud-based software. Basic ICU demographics (private or public, metropolitan or rural) and location, purchasing, airway management practices, guideline uptake, checklist and cognitive aid use and staff training relevant to airway management during the COVID-19 pandemic were the main outcome measures. The 69 ICU directors reported significant simulation-based inter-professional airway training of staff (97%), and use of video laryngoscopy (94%), intubation checklists (94%), cognitive aids (83%) and PPE “spotters” (89%) during the airway management of patients with COVID-19. Tracheal intubation was almost always performed by a Specialist (97% of ICUs), who was more likely to be an intensivist than an anaesthetist (61% vs 36%). There was a more frequent adoption of specific airway guidelines for the management of COVID-19 patients in public ICUs (94% vs 71%) and reliance on specialist intensivists to perform intubations in private ICUs (92% vs 53%).ConclusionThere was a high uptake of a standardised approach to airway management in COVID-19 patients in ICUs in Australia and New Zealand, likely due to endorsement of national guidelines.

Emergency Tracheal Intubation in Patients with COVID-19: A Single-center, Retrospective Cohort Study.

IntroductionThe objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation.MethodsWe retrospectively collected data on non-operating room (OR) intubations from February 1–April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient’s indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result.ResultsWe obtained 406 independent procedure notes filed between February 1–April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success.DiscussionAn average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.

Implementation of a Standardized Neonatal Intubation Training Package

To assess the first attempt neonatal intubation success rates of pediatric trainees following the implementation of an evidence-based training package. Data collection was undertaken from February, 1 2017, to January 31, 2018, to ascertain baseline preimplementation intubation success rates. An intubation training package, which included the use of videolaryngoscopy, preprocedure pause, and standardized instruction during the procedure, was introduced. Data on all subsequent intubations were collected prospectively from May 1, 2018, to April 30,2020. Preimplementation baseline data over a 1-year period demonstrated overall first attempt intubation success rate of junior trainees to be 37% (33/89). After implementation of the training package, 290 intubations were analyzed over a 2-year period. The overall success rate was 67% (194/290); 61% (117/192) for junior trainees and 79% (77/98) for senior clinicians. Three or more attempts were required for 13% of intubations (38/290). During the study period, the overall number of intubations being carried out decreased. Intubations with the videolaryngoscope had higher success rates for all tiers of clinician, most marked in the junior tiers. The introduction of a standardized intubation training package, along with videolaryngoscopy, improved trainee intubation success rates.

Economic analysis of the use of video laryngoscopy versus direct laryngoscopy in the surgical setting.

Aim: Compared with direct laryngoscopy (DL), video laryngoscopy (VL) offers clinical benefits in routine and difficult airways. The health economic benefit of VL versus DL for routine tracheal intubation remains unknown. Materials & methods: This analysis compared VL and DL health economic outcomes, including total inpatient costs, length of hospital stay (LOS), postoperative intensive care unit (ICU) admission and incidence of procedurally associated complications. Results: Patients with VL had decreased inpatient cost (US$1144-5891 across eight major diagnostic categories [MDC]); >1-day LOS reduction in five MDC; reduced odds for postoperative ICU admission (0.04-0.68) and reduced odds of respiratory complications in three MDC (0.43-0.90). Conclusion: Video laryngoscopy may lower total costs, reduce LOS and decrease the likelihood of postoperative ICU admission.

A randomized control led study comparing CMAC video laryngoscope and Macintosh laryngoscope for insertion of double lumen tube in patients undergoing elective thoracotomy.

Background and Aims:Double lumen tube (DLT) insertion for isolation of lung during thoracic surgery is challenging and is associated with considerable airway trauma. The advent of video laryngoscopy has revolutionized the management of difficult airway. Use of video laryngoscopy may reduce the time to intubate for DLTs even in patients with normal airway.Material and Methods:A total of 87 ASA 1–3 adults, scheduled to undergo elective thoracotomy, requiring a DLT were randomly allocated to videolaryngoscope (CMAC) arm or Macintosh laryngoscope arm. It was on open label study, and only the patient was blinded. The primary objective of this study was to compare the mean time taken for DLT intubation with CMAC (Mac 3) and Macintosh laryngoscope blade and the secondary objectives included the hemodynamic response to intubation, the level of difficulty using the intubation difficulty scale (IDS), and complications associated with intubation. Data was analysed using the statistical software SPSS (version 18.0).Results:The time taken for intubation was not significantly different (42.8 ± 14.8 s for CMAC and 42.5 ± 11.5 s for Macintosh laryngoscope P -0.908). The CMAC video laryngoscope was associated with an improved laryngoscopy grade (Grade I in 81.8% with CMAC and in 46.5% with Macintosh), less pressure applied on the tongue, and less external laryngeal pressure required. Hemodynamic responses to intubation were similar in both groups.Conclusion:Macintosh blade is as good as CMAC (mac 3) blade to facilitate DLT intubation in adult patients with no anticipated airway difficulty, however CMAC was superior as it offers better laryngoscopic view, needed less force, and fewer external laryngeal manipulations.

Conceptualizing intubation sharing: A descriptive qualitative study of videolaryngoscopy for pediatric emergency airway management.

This study characterizes clinical and educational practices around the use of videolaryngoscopy in pediatric emergency airway management through qualitative exploration. This is a descriptive qualitative study using semi-structured interviews of emergency medicine physicians. Physicians were selected by theoretical sampling from urban, tertiary care pediatric hospitals across the United States until theoretical data saturation was achieved. The study applied a constructivist grounded theory approach to data collection and analysis. Manual line-by-line coding of interview transcripts was used initially, then grouped into categories with constant comparative analysis to generate the final coding scheme organized by themes and subthemes. Finally, memo-writing and iterative analysis meetings explored relationships between themes and identified an interpretive model. Theoretical saturation was achieved after 10 of the initial 12 interviews. Emerging from the data were six themes that describe the concept of intubation sharing: (1) Videolaryngoscopy encompasses multiple modalities that all provide a shared view and ability to record; (2) Airway experts and systems help realize the full potential of videolaryngoscopy; (3) Videolaryngoscopy can be a clinical, educational, quality assurance and research tool; (4) Some skills required for videolaryngoscopyareunique, while others overlap with direct laryngoscopy; (5) Videolaryngoscopy allows a coaching laryngoscopist to provide real-time guidance to the primary laryngoscopist from a shared view; (6) Videolaryngoscopy provides an opportunity for post-intubation coaching and feedback and shared learning from a single experience for the provider community. Through this multicenter qualitative interview study, we derived the concept of intubation sharing through videolaryngoscopy for real-time and remote coaching, for both the primary laryngoscopist and the community of emergency medicine providers who intubate.

Comparison of Mc Grath-MAC and C-MAC video laryngoscopes for intubation in a COVID simulated mannequin by novice users wearing face protective gear

Introduction:Intubation in COVID patients is challenging. Various guidelines suggest the use of video-laryngoscope (VL) as the first device to aid intubation in a COVID patient. The best VL to facilitate intubation in such a setting especially by novices is not ascertained. We compared intubation characteristics by two VL's (McGrath-MAC and C-MAC) for intubation in a COVID simulated mannequin by novices.Methodology:This prospective randomized manikin-based crossover study was done in thirty medical professionals with no previous experience of intubation with VL. All participants were trained on Laerdel airway management trainer and were allowed 5 practice sessions with each scope with an intubation box while wearing face protective personal protective equipment (PPE). Participants were randomized into two groups of 15 each, one group performed the intubation first with McGrath and the other with C-MAC before crossing over.Results:The mean (S. D.) time to intubation was similar with both McGrath-VL and CMAC VL [31.33 (14.72) s vs 26.47 (8.5) s, P = (p-0.063)]. POGO score [mean (S. D.)] was better with CMAC [81.33 (16.24) vs 60.33 (14.73), p-0.00. The majority of the users preferred C-MAC VL for intubation (93.33%). The incidence of failed intubation and multiple attempts at intubating were similar with the two scopes.Conclusion:The time to intubation was similar with both VL's but the majority of novices preferred CMAC probably due to a bigger screen that helped them to have a better view of glottis in the COVID simulated mannequin.

Analysis of tracheal intubation in out-of-hospital helicopter emergency medicine recorded by video laryngoscopy

BackgroundTracheal intubation remains the gold standard of airway management in emergency medicine and maximizing safety, intubation success, and especially first-pass intubation success (FPS) in these situations is imperative.MethodsWe conducted a prospective observational study on all 12 helicopter emergency medical service (HEMS) bases of the Swiss Air Rescue, between February 15, 2018, and February 14, 2019. All 428 patients on whom out-of-hospital advanced airway management was performed by the HEMS crew were included. The C-MAC video laryngoscope was used as the primary device for tracheal intubation. Intubation procedures were recorded by the video laryngoscope and precise time points were recorded to verify the time necessary for each attempt and the overall procedure time until successful intubation. The videos were further analysed for problems and complications during airway management by an independent reviewer. Additionally, a questionnaire about the intubation procedure, basic characteristics of the patient, circumstances, environmental factors, and the provider’s level of experience in airway management was filled out. Main outcome measures were FPS of tracheal intubation, overall success rate, overall intubation time, problems and complications of video laryngoscopy.ResultsFPS rate was 87.6% and overall success rate 98.6%. Success rates, overall time to intubation, and subjective difficulty were not associated to the providers’ expertise in airway management. In patients undergoing CPR FPS was 84.8%, in trauma patients 86.4% and in non-trauma patients 93.3%. FPS in patients with difficult airway characteristics, facial trauma/burns or obesity ranges between 87 and 89%. Performing airway management indoors or inside an ambulance resulted in a significantly higher FPS of 91.1% compared to outdoor locations (p < 0.001). Direct solar irradiation on the screen, fogging of the lens, and blood on the camera significantly impaired FPS. Several issues for further improvements in the use of video laryngoscopy in the out-of-hospital setting and for quality control in airway management were identified.ConclusionAirway management using the C-MAC video laryngoscope with Macintosh blade in a group of operators with mixed experience showed high FPS and overall rates of intubation success. Video recording emergency intubations may improve education and quality control.

Ease of intubation and incidence of dental injury during direct laryngoscopy: A randomized controlled trial comparing five different laryngoscope blades (Macintosh, Miller, Reduce flange, Blechman and Flangeless)

BackgroundDirect laryngoscopy remains an invaluable and readily available option despite the increasing use of video laryngoscope for securing the airway in different situations, particularly in limited resource and unanticipated difficult airway scenarios. Several variations of the laryngoscope blades are available for various purposes. However, knowledge of the functioning of different blades in a similar controlled environment is required because of the unavailability of all blades in a given setting. AimThis study assessed the ease of intubation and the degree of dental injury with five types of laryngoscope blades (Macintosh, Miller, Reduced flange, Blechman, and Flangeless blade). MethodsThis prospective randomized controlled study was conducted in patients undergoing tracheal intubation with direct laryngoscopy using five different blades posted for elective surgery under general anesthesia in a single center.The primary outcome parameters were Cormack–Lehane grade and intubation difficulty score, whereas secondary outcome measures were the proportion and grades of dental injury. ResultsA Cormack–Lehane grade 3 view was observed more often with flangeless blades 7 (22.5%) than others, with the lowest incidence for the Macintosh blade 1 (3%) (p = 0.228). The first pass success rate was highest in Macintosh (94%), similar in reduced flange Macintosh and Blechman blades (90% each) and least in the flangeless blade (77%). The force required for laryngoscopy varied significantly between the blades (p < 0.001). The median interquartile range intubation difficulty score was the highest with flangeless blades [2 (2–3)] among all the groups (p = 0.048). The dental contact during laryngoscopy varied significantly between the groups (p < 0.001). The incidence of dental injury was the highest in flangeless (13%) among all the blades (p = 0.526). ConclusionsReduced flange Macintosh and Blechman blade had ease of intubation similar to standard Macintosh blade, where as flangeless blade is associated with more difficult intubations. Reduced flange Macintosh, and Blechman blades were associated with a lower incidence of dental contact and injury than other three study blades.

Video Laryngoscopy Improves Intubation Times With Level C Personal Protective Equipment in Novice Physicians: A Randomized Cross-Over Manikin Study.

The use of video laryngoscopes by novice physicians may improve first-pass success rates compared with direct laryngoscopy. The aim of the present study was to assess whether time to intubation, number of laryngoscopy attempts, and first-pass success rate during laryngoscopy with the video laryngoscope or conventional Macintosh laryngoscope are affected by personal protective equipment (PPE) donning. Seventy inexperienced physicians were randomly assigned to video laryngoscope or Macintosh groups and were instructed to perform intubation with both devices on a manikin, using PPE or a standard uniform. The primary outcomes were insertion time, number of laryngoscopy attempts, and first-pass success rates for each device with or without donning PPE. In the Macintosh group, significantly less time was needed for the first successful intubation without PPE vs. with PPE (12.17±3.69s vs. 24.07±5.09s, respectively; p<0.0001). On the other hand, such difference was not observed in the video laryngoscope group (14.99±3.01s vs. 14.01±3.35s, respectively; p=0.07). With PPE, the first-pass success rate was significantly higher in the video laryngoscope group [41 (58.6%) vs. 66 (94.3%), p<0.001]. The use of the video laryngoscope resulted in a significant decrease in insertion time compared with the Macintosh blade (14.01±3.35s vs. 24.07±5.09s, respectively; p<0.0001). First-pass success and insertion time with the video laryngoscope were not affected by PPE donning. However, both were negatively affected with the Macintosh laryngoscope.

Reply to: video laryngoscopy during airway management in COVID-19 patients.

Editor, We thank Hilbert1 for his interest in our previous work2 and appreciate the opportunity to respond. We absolutely agree that using a video laryngoscope, preferably with an external monitor, during intubation should be urgently included in the general recommendations for airway management in the care of patients with COVID-19. As we mentioned in our article in the last year's Christmas issue of the European Journal of Anaesthesiology, the use of video laryngoscope increases the distance between the face of the intubating person and the mouth of the patient, which is likely to reduce the risk of cross-infection of respiratory infectious diseases between patient and healthcare personnel. In our study, we also cultivated the patients’ exhaled gas colonies during intubation. However, these data were not reported in our article2 as we did not cultivate exhaled gas colonies before induction. Still, it is reasonable to conclude that the risk of cross-infection decreases with the increase of this spatial distance, which is also the reason why Dr Hilbert proposed separating the screen from the laryngoscope handle and using an external screen. Compared with the GlideScope, the handle of which is separated from the screen, our colleagues are more willing to use a video laryngoscope with a screen mounted on the handle, because it is lighter and more convenient in daily clinical practice. However, if we can make the split-screen video laryngoscope lighter and more convenient, our colleagues’ habits are likely to change radically. Although many countermeasures have been taken, the global spread of COVID-19 is strikingly fast3 and its contagion power is stronger than SARS-CoV and MERS-CoV.4 We agree that in addition to the consequent use of the personal protective equipment, we should reduce all procedures that are associated with the intense formation of aerosols to prevent further airborne spread of the virus as best as possible. All the intubation operators have been encouraged to use video laryngoscopy rather than direct laryngoscopy for intubation amid the COVID-19 outbreak in China.5 In addition, we also developed a new way to reduce the risk of cross-infection between anaesthesiologists and patients by using a uniquely designed protective sleeve (Fig. 1).6 This enable us to avoid self-contamination since that routine use of personal protective equipment is associated with frequent self-contamination, which is highest during removal of the equipment.7Fig. 1: Difference in intubation with or without the novel protective sleeve.In short, fighting with respiratory infection microorganism is a long process. With the advancement of technology, coupled with our continuous innovation, there will be more and more ways to deal with it, and the comprehensive use of these methods will allow us to increase the chance of defeating the disease. Hand in hand with peers around the world, we could finally conquer COVID-19 together. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: this work was supported by Postdoctoral Science Foundation of China (Grant No. 2019M663260 and No. 2020T130148ZX) and the Fundamental Research Funds for the Central Universities, China (Grant No. 20ykpy20). Conflicts of interest: none.

A questionnaire-based cross-sectional pilot survey on adherence to the recognized guidelines by the airway managers during intubation at the time of COVID-19 pandemic

Background and Aims: COVID-19 infection has the potential to spread exponentially during aerosol-generating procedures like intubation. The aim was to find the compliance toward the actual practice as well as the existing knowledge gap and adherence to the guidelines among the medical professionals while attempting intubation in a known or suspected COVID-19 patients. Materials and Methods: A cross-sectional web-based survey format was planned using English questionnaire in an online form (Google® Forms). One hundred and forty valid responses for 27 questions were received. Maximum participation was received from Indian anesthesiologists working in government, semi-government, and private health facilities, performing the intubation routinely. All the valid responses were statistically analyzed by calculating the significant difference in means and proportions, with P &lt; 0.05 being considered statistically significant. Results: Eighty percent of the respondents received training for donning and doffing and regularly wore personal protective equipment for the airway procedure. Scarce simulation training (22.1%), minimum screening before entering into a intubation scene (37.9%), frequent use of bag-mask ventilation (18.2%) or high flow nasal cannula (19.7%) use for preoxygenation, confirmation of the depth of endotracheal tube by auscultation (34.5%), and having no plan B in case of unanticipated difficult airway (27.9%) make the knowledge gap evident. The survey pointed out toward the infrastructural requirement of negative pressure intubation rooms, availability of waveform capnography, and widespread use of videolaryngoscope. Conclusion: This survey gives us an insight into the compliance with existing lacunae and nonuniform practices of the recommended guidelines for the airway management during COVID-19 pandemic with its pragmatic solution.