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A Comparison of Direct Laryngoscopy versus Videolaryngoscopy Using Aerosol

Box for Intubation in Emergency Surgeries during COVID‑19 Pandemic: A Pilot
Study

Article · September 2020

DOI: 10.4103/jmms.jmms_100_20

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Original Article

A Comparison of Direct Laryngoscopy versus

Videolaryngoscopy Using Aerosol Box for Intubation in
Emergency Surgeries during COVID‑19 Pandemic: A Pilot Study
Col Deepak Dwivedi, Col Parmeet Bhatia, Major Manish Aggarwal, Brig Subrato Sen, Col Bhavna Hooda, Col Puja Dudeja1
  Department of Anaesthesia and Critical Care, Command Hospital (Southern Command), Pune, Maharashtra, 1 Department of Preventive and Social Medicine,
Armed College of Medical Sciences, New Delhi, India

Abstract
Background and Aims: This study was planned to compare intubating conditions with aerosol box, while attempting intubation with either
direct laryngoscope (DL) using Macintosh blade or McGrath MAC™, videolaryngoscope (VL). Methodology: Sixty adult patients coming
for the emergency surgeries during COVID‑19 pandemic were divided equally by consecutive sampling into either Group 1 (DL) or Group
2 (VL). General anesthesia was administered with aerosol box covering the head and trunk of the patient. The laryngoscopy was attempted
based on the group allocation with either VL or DL through aerosol box. Following observations were noted, total intubation time, number of
attempts, Cormack–Lehane (CL) view, intubation difficulty scale (IDS), use of airway adjuncts, and external laryngeal maneuver. Results: Mean
(standard deviation) time taken to intubate was 25.36 (6.22) sec in DL group and 21.9 (5.56) sec in VL group. Median IDS scoring was 1 in DL
group and 0 in VL group indicating toward ease of intubation with the videolaryngoscope. Improved glottic view (CL Grade 1) was attained
commonly with VL group and higher CL grades (2b) were common with DL group (23.3%). No intubation aids were required in VL group
although 30% in DL required bougie for the intubation. External laryngeal maneuver was applied in 40% subjects undergoing DL with no
maneuvers needed in VL group. First pass success of intubation was comparable in both the groups. Conclusion: Intubating conditions are
favorable with VL when aerosol box is included which requires acquisition of the skills depending on its availability. However, the intubation
should be attempted with the technique the clinician has the expertise during this pandemic.

Keywords: Airway management, COVID‑19, endotracheal intubation, laryngoscopy, pandemic, personal protective clothing

Introduction under the condition of long exposure to high concentrations

of aerosols in a relatively closed environment.[2] To prevent
COVID‑19 pandemic is immensely challenging to
such transmission inside operating rooms “aerosol box” which
health‑care workers, more for those involved in aerosol
consist of transparent plastic cube to cover head and shoulders
generating procedures such as intubation, extubation,
of patient has been proposed.[3] It has two ports for inserting
oro‑tracheal suctioning, mask ventilation, tracheostomy, and
hands of clinician to facilitate airway management and some
cardiopulmonary resuscitation.[1] Although elective surgeries
modifications have additional port for assistance. This box
have been put on hold since the time it was declared pandemic,
is suggested, as an additional barrier along with face shield,
many patients may present in need of general anesthesia
goggles, and complete personal protective equipment (PPE)
for emergency surgeries. To decrease the risk of exposure
to decrease the risk of aerosol transmission.[4]
to anesthesia provider and staff, various guidelines, and
innovations have been suggested recently for safe, accurate and Address for correspondence: (Dr) Deepak Dwivedi,
swift management of airway in COVID‑19 patients. Although Department of Anaesthesia and Critical Care, Command Hospital (Southern
the main routes of transmission of COVID‑19 are droplets Command), Pune ‑ 411 040, Maharashtra, India.
E‑mail: deepakdwivedi739@gmail.com
and close transmission, aerosol transmission is also possible

Submitted: 25‑Jul‑2020 Revised: 12-Aug-2020  Accepted: 20-Aug-2020  Published: 09-Sep-2020

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How to cite this article: Dwivedi D, Bhatia P, Aggarwal M, Sen S,

DOI: Hooda B, Dudeja P. A comparison of direct laryngoscopy versus
10.4103/jmms.jmms_100_20 videolaryngoscopy using aerosol box for intubation in emergency surgeries
during Covid-19 pandemic: A pilot study. J Mar Med Soc 0;0:0.

© 2020 Journal of Marine Medical Society | Published by Wolters Kluwer - Medknow 1

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Dwivedi, et al.: Videolaryngoscope provides better intubating conditions
As the “aerosol box” increases the layer of barriers, simultaneously,
it increases the difficulty in airway handling because of poor
visibility of glottis and rapid fogging of goggles and face‑shield.
In addition, there is restriction in hand movements to facilitate
the swift and comfortable management of airway, with inherent
risk of breach in PPE with tear of gown and up rolling of
sleeves during the procedure.[5,6] Based on the advisory issued
by the Indian Society of Anaesthesiologist in April 2020 about
the management of the emergency cases during this pandemic,
the practice guidelines about intubation suggest, the use of
videolaryngoscope for intubation based on its availability as
it increases the distance between the operator and patient’s
head.[7] However, both availability and training or preference
of proceduralist with videolaryngoscope differs.[8] A systematic
review shows that there is no benefit in reducing intubation
attempts and time required for intubation with videolaryngoscope
compared to conventional direct laryngoscopy while managing
the airway without an aerosol box.[9]
This present study was, therefore, envisaged as one cannot
completely underplay the role of direct laryngoscopy over
videolaryngoscopy without a scientific evidence. Our study
aimed at comparing the intubating conditions in terms of first
attempt success of intubation, time required for intubation,
and intubation difficulty scale (IDS) scoring with aerosol box
placed in between the anesthesiologist and the patient while
attempting direct laryngoscopy/videolaryngoscopy during the
emergency surgeries.
Methodology
This pilot study was planned after obtaining the ethical clearance
from the institution ethics committee. All patients presenting
for the emergency surgeries in view of the cancellation of the
elective surgeries during this pandemic under general anesthesia
were included and consecutive sampling was done where the
first 30 patients were included in Group 1, direct laryngoscope
(DL) and the next 30 successive patients were included in Group
2, videolaryngoscope (VL). The basis of group division was the
method of laryngoscopy employed for the airway management
of these patients. The exclusion criteria included, age <18 years,
cervical spondylosis, restricted neck mobility, diabetes, severe
obesity, rheumatoid arthritis, thyromental distance of <6 cm,
and failure of intubation by DL. All patients were explained
and demonstrated the use of aerosol box preoperatively and
written informed consent was obtained.
Procedure
All patients on arrival in operation theater (OT) whether
tested prior or not, were considered as COVID suspect
and all standard precautions were taken during the aerosol
generating procedures such as intubation with confirmed
fasting. Patients were connected with the standard monitoring
and an intravenous (IV) access was obtained. The head of
the patient was made to rest on the gel ring to maintain the
head position, following which the aerosol box was placed
over the head end of the patient [Figure 1a]. Dimensions
2 Journal of Marine Medical Society  ¦  Volume XX  ¦  Issue XX  ¦  Month 2020
and specifications of aerosol box used were the same as
originally designed by Tseng and Lai of Taiwan.[10] After
donning the full protective clothing including the face shield
by the anesthesiologist, the preoxygenation was done with
the tight‑fitting mask [Figure 1a]. The induction was done
with injection propofol 2 mg/kg, fentanyl 1.5 µg/kg and rapid
sequence intubation without cricoid pressure was done at 60
s after the administration of the injection succinylcholine
2 mg/kg IV. Laryngoscopy was attempted with either standard
Macintosh laryngoscope or McGrath MAC™ (Medtronic,
India) videolaryngoscope based on the group selection by a
most experienced anesthesiologist [Figure 1b]. The following
parameters were noted which included, time to intubate in
seconds, number of attempts, Cormack Lehane (CL) view,
IDS, any airway adjuncts, or external laryngeal maneuver
used during the intubation. Time to intubate was defined
from the duration the laryngoscope blade is inserted till the
endotracheal tube is passed through the glottis and with the
confirmed trace on the capnograph. A progressive objective
assessment with IDS scoring entails seven parameters for the
quantitative assessment of the complex intubating conditions.
The parameters assessed are number of attempts and operators,
alternative techniques, CL Grade, lifting force, laryngeal
pressure, and vocal cord mobility. IDS score of 0 is considered
easy, 1–5 score is rated as slightly difficult and more than 5 is
considered a moderately difficult airway to major difficulty.[11]
Statistical analysis was done using the software, SPSS version
22 (SPSS Inc., Chicago IL, USA). Quantitative data between
the two groups were compared using the Student’s t‑test. The
discrete data are represented as mean (standard deviation) and
the ordinal data were calculated as median with interquartile
range. The significance of median between the two groups was
compared using two tailed Mood’s median test. The proportion
between the groups was analyzed with Z score calculator and
“N‑1” Chi‑square test.
Results
A total of 60 patients were included in the study after meeting
the inclusion criteria. The type of surgeries for which the
a b
Figure 1: (a) Preoxygenation with tight fitting mask through “Aerosol
Box.” (b) Improved glottic view achieved with Mc Grath MAC™
videolaryngoscope for intubation through “Aerosol Box”
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Dwivedi, et al.: Videolaryngoscope provides better intubating conditions

intubations were carried out in two groups are presented in

Table 1: Type of emergency surgeries in two groups for
Table 1. Comparison of demographic data in both the groups
which intubations were done
is shown in Table 2.
Types of surgeries Group 1 Group 2
Intubation characteristics were compared between the two Obstetric and gynecological emergencies 11 9
groups, where the intubation time measured for Group 1 (DL) Orthopedic surgeries 4 1
was 25.36 ± 6.22 s and was significantly shorter (21.9 ± 5.56 s) Oncosurgery 5 9
with the use of VL in Group 2 [Table 3]. Median IDS score Abdominal surgery 4 5
between the two groups were comparable [Table 3]. IDS score Neurosurgery 4 3
was uniformly distributed without any outliers as represented Plastic and vascular surgery 2 3
in the Box Plot figure [Figure 2]. Higher CL grade (2 b) was
observed more with the DL group [Table 3]. Group 1 also
required intubation aids and external laryngeal maneuver when Table 2: Comparison of demographic and the American
compared with the videolaryngoscopy group and the results were Society of Anesthesiologists profile of two groups
statistically significant [Table 4]. The intubation was done in
Observation Group 1 Group 2 P
the first attempt in majority of the cases in Group 1 and in all in
Age (years), mean±SD 43.03±18.9 40.73±16.11 0.61
Group 2 and the results were statistically insignificant [Table 4].
Weight (kg), mean±SD 67.73±7.87 67.46±8.50 0.89
Sex
Discussion Male 11 13 0.59
Inclusion of aerosol box during intubation as an innovative and Female 19 17 0.59
a barrier measure along with regular use of full PPE including ASA grade (%)
impermeable gown, face shield, goggles, and double gloves Grade I 26.6 30 0.77
Grade II 56.6 60 0.79
tend to decrease spread of aerosols to the anesthesiologist and
Grade III 16.6 10 0.45
other OT staff.[8] There are various modifications of intubation
P<0.05 is considered statistically significant. SD: Standard deviation,
box, originally designed by Tseng and Lai of Taiwan.[10] New ASA: American Society of Anesthesiologists
generation box include additional holes for bougie insertion and
suction port for creating negative pressure.[6] Vijayaraghavan
and Puthenveettil modified the dimensions of the box along Table 3: Comparison of Intubation time and Cormack–
with the shape and the location of inserting ports as per their Lehane grades with intubation difficulty scale scores in
study on mannequin.[12] Kloka et al. have designed an aerosol two groups
protection dome using packaging tray material used in bypass
Observations Group 1 Group 2 P
machine utilized for cardiac surgeries.[13] In the present study, (n=30) (n=30)
aerosol box used was the same in dimensions and specifications Intubation time (s), mean±SD 25.36±6.22 21.9±5.56 0.0268
as designed by Tseng and Lai of Taiwan and used by Canelli IDS scoring, median (IQR) 1 (3) 0 (1) 0.965
et al. to analyze aerosol spread in simulation, which proved to Modified CL Grade 1, 2a, 2b, 1: 50 1: 70 0.11
be an additional protection along with PPE.[4,10] 3a, 3b, 4 (%) 2a: 26.6 2a: 30 0.77
2b: 23.3 2b: 0 0.005
Aerosol box is fraught with innate challenges. Head of the P<0.05 is significant. CL: Cormack Lehane, SD: Standard deviation,
patient positioned over the pillow could not provide a stable IDS: Intubation difficulty scale, IQR: Indian quartile range
position due to the interface between the patient’s head and
the anesthesiologist. In our study, we have used gel rings for
positioning the head and maintained it successfully throughout Table 4: Comparison of intubation conditions in two
the intubation. In addition, to this we also placed folded towels groups
to accommodate the edges of aerosol box and its foot end Observations Group 1 Group 2 P
with drapes to reduce the spread of aerosol caudally as was (n=30), (n=30),
suggested by Singh et al. in their study.[5] n (%) n (%)
Requirement of intubation aids 10 (30) 0 (0) 0.001
Several other factors are known to cause intubation difficulty
Requirement of laryngeal 12 (40) 0 (0) 0.0001
using aerosol box like, restriction in hand movements to facilitate manipulation
airway positioning and mask holding[8,12] and poor glottic view Intubation in first attempt 27 (90) 30 (100) 0.07
due to multiple barriers with fogging of goggles.[14,15] Similar P<0.05 is significant
difficulties were observed initially in our center too, but we
improved with simultaneous practice on mannequin resulting in
pass chances of intubation with the complete avoidance of
better ergonomics and successful attempts to intubation.
close contact to patient’s airway.[7,8,15] Although literature
Recent guidelines preferred videolaryngoscopy over on comparison of videolaryngoscope with Macintosh
conventional direct laryngoscopy in view of increased first laryngoscope during adult intubation suggest, either there is

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Dwivedi, et al.: Videolaryngoscope provides better intubating conditions
a b
Figure 2: Comparison of intubation difficulty scale scores in two groups
Box and Whisker Plot: (a) The direct laryngoscopy group. (b) The
videolaryngoscopy group
no increase or rather decrease in first attempt intubation.[9,16]
While in contrast, there is a greater first pass success rate
and improved glottic visualization in outside operating room
scenario among less experienced clinicians with the use of VL
when compared to DL. The results were contrary in the same
study with the experienced clinicians when both VL and DL
were compared.[17] In our study, first pass intubation success
was 100% and 90% for VL and DL respectively in the hands
of an experienced anesthesiologists [Table 4].
The study reported improved glottic view in majority (70%)
of the subjects having CL Grade 1 in VL group when was
compared with DL group [Table 3]. The observations are in
accordance with the Cochrane review done by Lewis et al.
where VL was found to minimize the difficult glottic view.[9]
Similar improvement in CL grade with VL was observed
during out of hospital cardiopulmonary resuscitation.[18] In
addition to the ergonomics involved while doing the intubation
through the aerosol box we also observed that while
attempting intubation with DL, there was a hindrance due to
altered intensity and brightness of Macintosh laryngoscope
light reflecting from the various interface such as aerosol box,
face shield, and goggles.
Intubation aids including stylet and bougie, are considered
integral part of difficult airway cart in COVID‑19 patients
and as per Difficult Airway Society guidelines, preferably the
endotracheal tube must be loaded with a bougie or it should
be readily available in the vicinity while using Macintosh
laryngoscope.[19] In present study, nine (30%) cases in DL group
required adjuncts; like bougie and 11 (40%) cases required
assistance in the form of external laryngeal manipulation to
facilitate intubation. The results were clinically as well as
statistically significant, when they were compared to VL group
[Table 4]. VL minimizes the chances of aerosol spread caudally
from the aerosol box with minimal assistance required in terms
of the adjuncts as well as external laryngeal pressure. Kojima
et al. have used a modified enclosure device to achieve airtight
4 Journal of Marine Medical Society  ¦  Volume XX  ¦  Issue XX  ¦  Month 2020
conditions, which allows assisting staff to access through
barrier without exposure to aerosols.[20]
The IDS scoring, as a marker of difficulty faced during
intubation was used in this study. It takes into account both
objective and subjective criteria, which evaluates intubation
difficulty including CL grade.[11] Overall IDS score was not
more than five in any of the patient in both groups, although in
DL group, fifteen patients had IDS score in range of 1–5 (slight
difficulty) while in VL group only nine patients had IDS score
of 1 (slight difficulty). Similarly, Loughnan et al. compared
performance of DL and VL in terms of IDS, found higher score
in DL but the results were not statistically significant as was
evident in our case.[16] Kim et al. compared the two intubation
modalities in children, and found significantly higher IDS score
in direct laryngoscopy.[21] Jafra et al. also concluded that the
ease of endotracheal intubation was better with Glidescope
videolaryngoscope when compared with DL having the higher
IDS scores.[22]
Cochrane systematic review by Lewis et al. showed no
difference in the intubation time between the VL and DL
and they attributed it to the heterogeneous data related to the
varied definition of the time to intubate which was obviated
from the meta‑analysis.[9] However, time to intubation was
shorter with VL than DL during nasotracheal intubation and
in obese subjects in various studies.[23,24] The intubation time
when compared between the two groups in our study was
statistically significant with DL group taking more time for
intubation.[Table 3] This could be perhaps related to the
manual dexterity issues with the use of DL with inclusion of
aerosol box for intubation and increased interfaces making
the airway iatrogenically difficult and hence, increasing the
time to intubate.
The strength of this study is to provide the insight into the
intubating conditions when it is compared between the
preferred modality (videolaryngoscope) and the most widely
used direct laryngoscopy for intubation during the pandemic.
Being a pilot study is a limitation, but it can act as a prelude
to conduct randomized controlled trials with collation of data
from the multiple center, which will aid in substantiating its
results for providing the safer airway management which will
benefit both, the patient as well as the health‑care provider.
Conclusion
COVID‑19 pandemic situation made the use of aerosol box
as an effective and definitive barrier measure during airway
management to prevent the operator and OT staff from aerosol
transmission. At the same time, difficulty arise in handling
airway, which may be handled better with the familiar
technique of intubation with either DL or VL depending on
the expertise and the availability. VL is although preferred
and advocated as it improves the glottic view, with shorter
intubation time with lesser use of adjuncts, external laryngeal
manipulation and lower IDS score.
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Dwivedi, et al.: Videolaryngoscope provides better intubating conditions
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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