Videolaryngoscopes (VLs) are increasingly re-commended in paediatric [1] and adult [2–5] difficult-airway guidelines. A Cochrane review showed decreased airway complications and fewer unsuccessful tracheal intubations when using VLs [6]. A high first-pass success rate [7], reduction in cervical spine motion [8], improvement of glottic visua-lization [9], and decreased mucosal trauma incidence [10] are among the proven advantages of VLs over direct laryngoscopes.
Although VLs improve first-attempt success rates and the laryngeal view, and seem to shorten intubation time, this improvement varies between diffe-rent laryngoscopes [11]. However, the selection of an appropriate type of VL for specific situations is still controversial [12]. The availability of the VL, the conditions under which it is preferred, and the blade selection vary between hospitals and countries. National surveys about videolaryngoscopy are available from different countries with a broad variety of availability, distribution in clinics, and access, as well as the most commonly available videolaryngoscope types.
Today, with challenges posed by COVID-19, the VL is recommended as the first-line strategy for airway management [13–15]. During the COVID-19 pandemic the importance of VLs was emphasized in reducing the risk of infection during tracheal intubation [16] because the use of a VL increases the spatial distance between the patient and the practitioner [17]. Thus, this potentially protective effect on personnel increases [18], and the routine use of VLs and is now recommended in the consensus guidelines of airway management in patients with possible SARS CoV-2 infection [19]. However, limited information is available how the COVID-19 pandemic has changed airway management practice. The primary aim of this before-and-after cross-sectional survey study was to assess the frequency of the use of VLs in the operation theatres in different countries before and after the first 3 COVID-19 pandemic waves. The secondary outcome measures included a comparison of the characteristics of preferred VLs.
METHODS
Following the approval of the University of Health Sciences Kartal Dr. Lutfi Kirdar City Hospital Ethics Committee (president: Nejdet Bildik, registration number: 2021/514/204/31, date of approval 22/06/2021) in Istanbul, Turkey, anaesthesiologists were invited to participate in the survey by e-mail through the European Airway Management Society’s network (www.eamshq.org). Prospective data collection was performed in 2 stages. Two questionnaires were sent out and were open for one month, the first from January 2019 to February 2019 and the second from July 2021 to August 2021, using the online platform at www.surveymonkey.com. The questionnaire was composed of 16 questions arranged in different domains: participants’ demographic data; the frequency of VL use; situations where VL was preferred; use of VLs as a rescue device; types of VLs used; rate of VL use in non-difficult airway management and in daily clinical practice; blade preferences; and a protocolized approach to easy laryngoscopy and during non-intubatable situations (Appendix 1). The survey also asked to evaluate channelled versus non-channelled VLs in terms of ease of use, learning curve, ease of cleaning (for reusable devices), costs, and specific features. The same questions were asked in the second survey after the COVID-19 outbreak.
Participants who agreed to participate in the survey and gave consent to the study were included. The respondents’ characteristics were recorded, including age, sex, and professional experience.
Statistical analysis
Participants’ responses were reported as descriptive statistics and presented as mean ± standard deviation using IBM SPSS Statistics 22 (Armonk, NY: IBM Corp). Subgroup analysis evaluated differences between countries, bed capacities of the hospitals, and the location where the participants were working. In the pairwise comparison of numerical data groups, an independent samples t-test was used for those with normal distribution, Mann-Whitney U test, and one-way ANOVA test for those which did not. The χ2 test was used to analyse discrete variables, and the Kruskal-Wallis H test was used to examine multiple groups. P < 0.05 was considered as significant.
RESULTS
A total of 791 anaesthesiologists were invited to participate in this survey; 155 (19.5%) responded to the first survey and 91 (11.5%) to the second survey. The invited anaesthesiologists were the same in both surveys, and the surveys were same. 91 participants answered both the first and second survey.
The survey cohort before and after the COVID-19 pandemic
The mean age of the participants in the survey before and after COVID-19 was similar (P = 0.326, Table 1). The level of experience with VLs was also similar in the before/after surveys (P = 0.209). Gender distribution, the duration of professional experience and bed capacity in the hospitals were also found to be similar (Table 1). After the pandemic, VL availability increased significantly, whereas experience with VLs did not change. The preference for use of VLs was 24.1 ± 27.5% before COVID-19 and 43.1 ± 37.7% after the COVID-19 pandemic (P < 0.001, Table 2).
TABLE 1
The comparison of participants’ characteristics, professional experience, and bed capacity of the hospitals they work in before and after COVID-19
TABLE 2
Videolaryngoscope use before and during the COVID-19 pandemic
The rate of VL use in all participants increased from 14.2% to 38.5% (P < 0.001, Table 2). The rate of VL use just for difficult intubation, the rate of use of the VL as a rescue device, the type of VL, and type of blade preference, and indications for use of a hyper-angulated blade did not differ before and after the pandemic.
Participants evaluated the videolaryngoscopes according to the following questions regarding the use of channelled and non-channelled videola-ryngoscopes: easy to use, easy to learn, easy to clean, low cost, anti-fog, reusable, connection with smart phone, pocket monitor, dedicated stylet, battery life, paediatric blade, lifetime of device, recording options, no waiting time before use, O2 and suction line, and adjustable length. There was no difference in preferences and opinions before and after the COVID-19 pandemic (P = 1.000, Table 3).
TABLE 3
Comparison of channelled and unchannelled videolaryngoscopes
DISCUSSION
Our findings may reflect an interesting attitude during the COVID-19 pandemic: on the one hand, the increased trend of use of VLs, clearly perceived as an effective, high-success, and safer device; on the other hand, maintaining the pre-pandemic preferences for type of VL and blade may reflect the preference of what is well known and what physicians feel confident with.
Airway management is routinely applied by anaes-thesiologists, emergency medicine physicians, and intensivists. However, airway management may be catastrophic and fatal if complications occur [20], and non-compliance with current guidelines is associated with poor patient outcomes [21]. Increasing the use of VLs in hospitals may result in an improvement in patient safety and needs to be an aim for anaesthesia and airway societies and their educational programs. Guidelines and consensus statements recommend the use of VLs in the airway management of patients with COVID-19 [22]. The aim behind this approach was clearly to enhance the first-pass success rate in physiologically difficult airway patients, ensuring at same time increased protection from SARS-CoV-2 infection for the intubation team [23]. We observed a significant increase in the percentage of VL users in the before/after pandemic responses. This finding may have multiple meanings: in the critical and relatively unknown setting of the SARS-CoV-2 challenge, physicians felt safer and more secure in following available guidelines, which included use of videola-ryngoscopes, which shows the high rate of com-pliance with the guideline recommendations.
As a further point, we believe that enhanced and more frequent use of VLs during and after the pandemic, will represent a great opportunity for training [24], with significant implications for the future use and performance of VLs, given that recent data clearly show the impact of expertise with VLs on the rate of first-pass intubation success [25]. Furthermore, videolaryngoscopes favour the intubation of a physiologically difficult airway in a highly demanding environment [26]. Therefore, it is obvious that VLs should be used as primary devices for treating the airway in the pandemic.
Little is known about the availability of VLs, and even less during the COVID-19 outbreak. Before the pandemic, availability of VLs was reported with variable percentages in different countries: 65% from the Hungarian Society of Anaesthesiology and Intensive Therapy [27], 56.8% as found in Swedish hospitals [28], and as 57.5% in the UK [29]. The second (after pandemic) survey clearly showed an unprecedented result, i.e. the 100% availability and access to VLs reported by participants. In contrast, the earlier reports of the pre-pandemic survey found about 24.1% use of VLs, with 6% of centres not having a VL.
The second survey was conducted 1.5 years after the initial COVID-19 outbreak, in January 2020, and we believe that this time frame clearly depicts the actual situation, given that probably an earlier survey would have not shown such ubiquitous availability of VLs.
According to our knowledge, this study is the first one to compare the use of VLs before and after COVID-19. The lack of such data in the literature reveals one of the strongest aspects of our study. In another UK survey conducted before the COVID-19 pandemic, the rate of hospitals having VL access was reported as 92% [30]. But fewer than one in three of these hospitals were using VLs routinely to manage the airway. In our study, we observed that the routine use of VLs in all cases increased 3-fold during the pandemic. This issue was even advocated before the pandemic [31].
In a study including 3668 cases at study baseline and 3786 cases at follow-up, routine use of VLs is an effective factor in reducing the incidence of adverse airway events [32]. In the specific setting of COVID-19, VLs may provide at the same time a higher rate of successful tracheal intubation compared to standard direct laryngoscopes [33, 34], while giving more protection for airway providers due to increased mouth-to-mouth distance, minimized risk of aerosolization [35], and shorter patient-contact time.
We believe that this finding may have implications also on the endemic phase of COVID-19 in the coming years: with an estimated SARS-CoV-2 infection rate in elective surgical patients of 1–9% [36], and given the time and cost burdens of preoperative nasopharyngeal swab testing [37], wider routine use of VLs may increase healthcare providers’ safety and reduce infection risks, especially with SARS-CoV-2 asymptomatic or incubating patients.
There are several comparative studies on the performance of different VLs in COVID-19 patients [38, 39]. We evaluated that the frequency of VL use increased during the COVID-19 pandemic without differences in preferred blade or VL type. Studies comparing channelled versus non-channelled VLs have reported controversial results. Biro et al. [40] reported that non-channelled VL shortened the time to achieve glottis visualization but extended the total airway management duration. Padhy et al. [41] reported higher success rate and shorter time with the Airtraq (Prodol, Vizcaya, Spain) channelled VL compared to the McGrath VL (Medtronic, USA). On the other hand, another study comparing the channelled and non-channelled versions of different VLs did not show any difference in terms of first-pass intubation success rate [42]. We explored both channelled and non-channelled VLs in detail regarding their different features, including the ease of use, cleaning, and learning, cost, dedicated stylet, and some technical specifications, finding that there was no significant change after COVID-19. Current airway guidelines provide no clear recommendations regarding the use of different blade types. Further studies are required in this field.
The most important limitation of this study is the relatively low response rate to our invitation. There might be limitations regarding language use in such an international survey in English, and there might be also a bias towards airway enthusiasts participating in such a survey. We ascertained that the COVID-19 pandemic influenced the availability and the use of VLs. However, further studies are needed to see if this increase leads to a reduction in the complication rate or the incidence of emergency front of neck access.
The survey reflects that the COVID-19 pandemic significantly increased the availability and use of VLs in operating theatres, and that a larger number of anaesthesiologists now use it routinely in all cases. This finding may have important implications on training and expertise development, with long-term results in terms of the proficiency and efficacy of VLs. The preferred type of VL or blade did not change during the pandemic. Further studies are needed to address specific unanswered questions.
