Abstract:

Introduction:

The orotracheal intubation is an important procedure in airway management, especially when performed in emergency situations. Video-laryngoscopy is an artifice that facilitates visualization of the glottis, aiding intubation.

Objective:

This study aimed to attach a video camera to a conventional Macintosh-type laryngoscope to enable and train intubation or otracheal training.

Method:

The use of a camera coupled to a conventional laryngoscope allows direct and indirect visualization of the glottis. Camera images can be transmitted over wi-fi and shared to electronic devices and platforms, aiming at teaching in person or remotely about orotracheal intubation.

Result:

The use of the device as a method of teaching intubation or otracheal, allows teaching to teach the theory of procedure and training the execution performed by the artisanal method. This feedback in the practical training of orotracheal intubation in mannequins can be performed in person or remotely.

Conclusion:

The use of handcrafted video laryngoscopy device in medical education is a low-cost tool to improve conventional orotracheal intubation training.

Keywords:
Laryngoscopy; Intubation Intratracheal; Teaching; Airway Management; Simulation Training

Resumo:

Introdução:

A intubação orotraqueal é um procedimento importante no manejo da via aérea, principalmente quando realizada em situações de emergência. A videolaringoscopia é um artificio que facilita a visualização da glote ao auxiliar a intubação.

Objetivo:

Este estudo teve como objeto acoplar uma câmera de vídeo a um laringoscópio convencional do tipo Macintosh para possibilitar e orientar o treinamento da intubação orotraqueal.

Método:

O uso de uma câmera acoplada a um laringoscópio convencional permite a visibilização direta e indireta da glote. As imagens da câmera podem ser transmitidas por wi-fi e compartilhadas para dispositivos e plataformas eletrônicos, visando ao ensino presencial ou remoto da intubação orotraqueal.

Resultado:

A utilização do dispositivo artesanal como método de ensino de intubação orotraqueal permite ao docente ensinar a teoria do procedimento e orientar e corrigir a execução realizada pelo acadêmico. Esse feedback no treinamento prático pode ser realizado presencialmente ou por via remota.

Conclusão:

O uso do dispositivo artesanal de videolaringoscopia no ensino médico é uma ferramenta de baixo custo para aperfeiçoar o treinamento de intubação orotraqueal convencional.

Palavras-chave:
Laringoscopia; Intubação Orotraqueal; Ensino; Manuseio das Vias Aéreas; Treinamento com Simulação de Alta Fidelidade

INTRODUCTION

Orotracheal intubation is one of the most important procedures in airway management. It provides adequate oxygenation and ventilation for patients and ensures airway protection¹1. Nausheen F, Niknafs NP, MacLean DJ, Olvera DJ, Wolfe AC, Pennington TW, et al. The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis. Scand J Trauma Resusc Emerg Med. 2019;27(1):1-9.. Emergency intubations are more difficult due to factors related to the patient, the operator and the environment. When the three factors are added, intubation becomes a procedure with potential for major complications²2. Suzuki K, Kusunoki S, Tanigawa K, Shime N. Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study. BMJ Open. 2019;9(3):1-7.^),(33. Pieters BMA, Wilbers NER, Huijzer M, Winkens B, Van Zundert AAJ. Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel. Anaesthesia. 2016;71(5):556-64.. The COVID-19 pandemic is a good example of this situation. The high transmissibility by droplets and aerosols requires the use of personal protective equipment (PPE), making it difficult to adequately visualize the oropharynx during the orotracheal intubation procedure⁴4. Associação de Medicina Intensiva Brasileira. Recomendações da Associação de Medicina Intensiva Brasileira para a abordagem do Covid-19 em medicina intensiva. São Paulo: Amib; 2020.^),(55. André RPD, Oliveira HC de, Gouvêa G, Fernandes FC, Jerônimo IRL, Campos JF. Treinamento de intubação orotraqueal na pandemia por coronavírus: aplicação da Prática Deliberada em Ciclos Rápidos. Rev Bras Educ Med. 2021;45(3):1-8..

It is estimated that approximately 3% of patients with COVID-19 will require orotracheal intubation at some point during the course of the disease⁶6. Meng L, Qiu H, Wan L, Ai Y, Xue Z, Guo Q, et al. Intubation and ventilation amid the Covid-19 outbreak: Wuhan’s experience. Anesthesiology. 2020.. In Brazil, a study reports that 4 of 10 patients with indication for hospitalization required a definitive airway with mechanical ventilation⁷7. Brandão Neto RA, Marchini JF, Marino LO, Alencar JCG, Lazer Neto F, Ribeiro S, et al. Mortality and other outcomes of patients with coronavirus disease pneumonia admitted to the emergency department: a prospective observational Brazilian study. PLoS One. 2021;16:1-15.. The Brazilian Association of Intensive Medicine (AMIB, Associação de Medicina Intensiva Brasileira) recommends the use of a videolaryngoscope to facilitate the intubation technique⁴, taking into account the increased difficulty of intubation in COVID-19 patients and the high demand for this procedure.

Recent studies have shown that video-assisted laryngoscopy does not increase the success of orotracheal intubation nor does it reduce complications when compared to conventional laryngoscopy. However, video-assisted laryngoscopy improves the visualization of the glottis and, for less experienced professionals, contributes to greater confidence when performing the procedure⁸8. Janz DR, Semler MW, Lentz RJ, Matthews DT, Assad TR, Norman BC, et al. Randomized trial of video laryngoscopy for endotracheal intubation of critically ill adults. Crit Care Med. 2016 Nov 1;44(11):1980-7.. Better visualization helps in the training of less experienced physicians performing orotracheal intubation of manikins. This corroborates the fact that the worse the scenario in the simulations, the greater the efficiency of video-assisted intubation when compared to conventional laryngoscopy⁹9. Kaplan A, Göksu E, Yildiz G, Kiliç T. Comparison of the C-MAC videolaryngoscope and rigid fiberscope with direct laryngoscopy in easy and difficult airway scenarios: a manikin study. J Emerg Med. 2016;50(3):e107-14..

Therefore, video-assisted intubation training can bring positive results to medical education, since it facilitates learning about airway access¹⁰10. Choo HJ, Kwon OY, Ko YG. Educational suitability of endotracheal intubation using a video-laryngoscope. Korean J Med Educ. 2015 Dec 1º;27(4):267-74. Disponível em 22/02/2022: Disponível em 22/02/2022: http://kjme.kr/journal/view.php?doi=10.3946/kjme.2015.27.4.267 .
http://kjme.kr/journal/view.php?doi=10.3... . It may be possible to adapt a low-cost device with a camera to the conventional laryngoscope for the teaching of orotracheal intubation in a remote teaching environment.

METHODS

The handcrafted device for video-laryngoscopy (Figure 1) is a low-cost adaptation of indirect (video-assisted) laryngoscopy, at a cost of US$20.00. it allows training on manikins in two modalities: direct laryngoscopy (without device) and indirect (with a device). The device with the camera is coupled to a conventional Macintosh-type laryngoscope (Table 1). The endoscopic camera is a 2.0 megapixel Wi-Fi Wireless Endoscope, with a diameter of 8mm, and variable cable length depending on the manufacturer. It has a USB output at its end, which allows direct connection to cell phones, computers or tablets, or even to a Wi-Fi transmitter (Wireless Fidelity), which allows visualization of laryngoscopy within a radius of 5 to 30 meters. The image has a focal length of 4 to 6 cm and the LED light (light-emitting diode) of the camera associated with the light from the conventional laryngoscope improves the visualization of the oropharynx image.

Figure 1
Low-cost handcrafted device for videolaryngoscopy.

The base of the camera is attached to a malleable metal alloy, enabling the adaptation to the laryngoscope blade (according to the step-by-step diagram in Chart 1). It can be used on any laryngoscope blade, regardless of the number. For this purpose, the handcrafted device needs a distance of 2 cm from the distal end of the blade. The double-sided adhesive tapes assist in introducing and removing the device, facilitating its use when videolaryngoscopy is required.

Chart 1
Device assembly guidelines

RESULTS

The handcrafted videolaryngoscopy device connects to electronic devices (e.g., cell phones). The visualization of the laryngoscopy image can be visualized in three situations: directly on the electronic device that is connected to the USB output; if connected to the box that transmits the Wi-Fi, it can be seen by electronic devices connected in a close radius (5-30 meters), without device limit (e.g., in a classroom - Figure 2); and if the videolaryngoscopy device is connected to the computer, the image can be transmitted remotely, through virtual platforms, to other electronic devices regardless of the distance (Figure 2).

Figure 2
Low-cost handmade device application.

DISCUSSION

Adequate airway management is a factor that can save lives; for it to be successful, the health professional must have adequate mastery of the laryngoscopy technique and know how to deal with factors that increase the procedure complexity, such as environmental factors and patient profile³3. Pieters BMA, Wilbers NER, Huijzer M, Winkens B, Van Zundert AAJ. Comparison of seven videolaryngoscopes with the Macintosh laryngoscope in manikins by experienced and novice personnel. Anaesthesia. 2016;71(5):556-64.. The use of video devices in these procedures has improved performance in orotracheal intubation, both in the procedure itself and in its use for medical training. Videolaryngoscopy improves the visualization of oropharyngeal structures, increases the distance between the face of the person performing the orotracheal intubation and the patient’s oral cavity. This allows an adequate approach in complicated intubations¹¹11. Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, et al. Emergency tracheal intubation in 202 patients with Covid-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth. 2020;125(1):e28-37.. It reduces the exposure of the patient’s oropharyngeal secretions to the team performing the intubation, as well as reducing the possibility of infections such as COVID-19.

The video laryngoscopy device has satisfactory rates regarding orotracheal intubation in patients with no experience with conventional laryngoscopy¹²12. Mackie S, Moy F, Kamona S, Jones P. Effect of the introduction of C-MAC videolaryngoscopy on first-pass intubation success rates for emergency medicine registrars. Emerg Med Australas. 2020;32(1):25-32.. Pieters et. al. (2016) used seven models of video laryngoscopes (indirect visualization of the oropharynx) and compared them with the laryngoscope with direct visualization (classic, Macintosh type) in intubations with manikins. He observed that all were better with conventional laryngoscopy - possibly because it was a model that everyone already had contact with. When comparing the video-laryngoscopes, the devices that have a Macintosh-type blade (e.g., C-MAC) showed a more agile intubation and had a higher degree of satisfaction. The study also reports that with models with a non-classical blade, such as the Airtraq and Pentax AWS, the groups needed more attempts to be even successful, possibly because it was a laryngoscopy blade with a new conformation, unfamiliar to the assessed professionals. The handcrafted device adapts the Macintosh-type blade, and its use allows training in direct and indirect laryngoscopy, as the device is easily attached to the laryngoscope and can be removed at any time.

The visualization with details of the oropharyngeal structures collaborates with the success of the orotracheal intubation procedure, facilitating the teaching in simulations, in the teacher’s demonstrations to the student and the visualization of the procedure performed by the student to be appraised by the teacher. Thus, the skills acquired in simulation environments, allows training that can result in improvements in outcomes for real-life patients, in which some studies demonstrate a reduction in mortality¹³13. Boet S, Bould MD, Fung L, Qosa H, Perrier L, Tavares W, et al. Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Can J Anesth. 2014;61(6):571-82..

Social distancing measures have affected universities during the pandemic. The migration from face-to-face activities to remote ones through virtual platforms added difficulties in relation to the teaching of practical skills in medical training¹⁴14. Alcântara L de AR de, Murta KMP, Souza TNVP, Molinari-Gomes LC. Mentoria: vantagens e desafios da educação on-line durante a pandemia da Covid-19. Rev Bras Educ Med . 2021;45(supl 1):1-6.. The use of video devices, associated with technologies such as transmission of images via Wi-Fi (one can view the image with the performer close by), or image transmission through sharing on virtual platforms, helped in academic teaching. The low-cost video-laryngoscopy device facilitates the practice of intubation, as well as allowing its use for demonstration of the procedure and assists in the visualization for those involved in the teaching of orotracheal intubation. This study is limited to the expository method of a teaching model using a handcrafted video laryngoscopy device, and the teaching method was not validated.

CONCLUSIONS

The use of the low-cost handcrafted device can be part of the technical teaching of orotracheal intubation. Its application in medical teaching can be used in-person or remotely, improving the visibility of the oropharynx. This possibility of use complements traditional teaching and opens doors to other teaching modalities.

REFERÊNCIAS

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