Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
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Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : UC15 - UC19 Full Version

Comparison between Direct Laryngoscopy with and without Aerosol Box for Intubation in Patients Undergoing General Anaesthesia during COVID-19 Pandemic- A Randomised Controlled Study


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/56601.16454
Krupa P Patel, Ashish P Jain, Vaidehi J Mehta, Hetal A Parikh, Chinar N Patel

1. Assistant Professor, Department of Anaesthesiology, Parul Institute of Medical Science and Research, PIMSR, Parul University Vadodara, Gujarat, India. 2. Assistant Professor, Department of Anaesthesiology, Parul Institute of Medical Science and Research, PIMSR, Parul University Vadodara, Gujarat, India. 3. Associate Professor, Department of Microbiology, Parul Institute of Medical Science and Research, PIMSR, Parul University Vadodara, Gujarat, India. 4. Professor and Head, Department of Anaesthesiology, Parul Institute of Medical Science and Research, PIMSR, Parul University Vadodara, Gujarat, India. 5. Professor, Department of Anaesthesiology, Parul Institute of Medical Science and Research, PIMSR, Parul University Vadodara, Gujarat, India.

Correspondence Address :
Dr. Vaidehi J Mehta,
Flat A-501, Tower-5, Vraj-Nandan Flats, Aryakanya Road, Near Hiravanti Chamber,
Karelibaug, Vadodara-390018, Gujarat, India.
E-mail : dr.aashish.jain@gmail.com

Abstract

Introduction: The airway management of patients with COVID-19 is a high risk task for anaesthesiologists. Several innovations have been born as a result of this problem, including aerosol boxes and clear plastic sheets.

Aim: To compare the timing and attempt of direct laryngoscopy with and without aerosol box for intubation in patients undergoing general anaesthesia during the COVID-19 pandemic.

Materials and Methods: This was a randomised controlled study was conducted in Parul Sevashram Hospital, Parul University, Vadodara, Gujrat, India from April 2021 to September 2021. A total of 50 patients were randomly divided into two equal groups as group A was intubated with an aerosol box and a macintosh laryngoscope, while group B was intubated with a clear plastic sheet and macintosh laryngoscope. With proper airway precautions and Personal Protective Equipments (PPE) comparative assessment of patients undergoing surgery in general anaesthesia was done. Time to intubate, number of attempts, ease of Endotracheal Tube (ETT) tube insertion, quality of Laryngoscopy view and Cormack Lehane scores were assessed in both the groups.

Results: The mean time for intubation was high at 29.72 seconds in group A, while it was 23.16 seconds in group B; the difference was significant. Overall, 20 out of 25 (80%) patients could be intubated in 1st attempt in group B as compared to 15 out of 25 (60%) in group A. Airway visualisation using Percentage of Glottic Opening (POGO) scoring and Cormack Lehane staging were suggestive of better visualisation in group B than group A. Difficulties encountered during intubation like laryngoscopy, glottic visualisation, arm movement restriction, ETT negotiation, and stylet removal were lesser in group A as compared to group B. The incidence of complications like sore throat and airway bleeding were lower in group B as compared to group A.

Conclusion: In the COVID-19 era, aerosol box and clear plastic sheets are effective barrier measures for airway management to prevent the anaesthesiologists from the aerosol transmission. But airway management with clear plastic sheet is technically easier than aerosol box.

Keywords

Aerosol barrier, Endotracheal intubation, Laryngoscopes, Personal protective kits

In early 2020, the rapid surge of the Coronavirus pandemic 2019 (COVID-19) put anesthesiologists at the leading edge. COVID-19 disease has a propensity to spread to the healthcare workers involved in the care of the patients, primarily during airway management (1).The unexpected surge of patients brought about an unanticipated scarcity in protective systems needed to guard Healthcare Workers (HCWs) during intubations from a exceedingly contagious virus. Numerous innovations were born as direct requirement to tackle the problem. Among them, clear plastic sheet and the aerosol box have become quite popular within the anaesthesia community (2).

Endotracheal intubation, however, is an aerosol generating procedure and imposes a potential risk for aerosol based transmission. To reduce the aerosol exposure to the clinicians multiple protective and cost effective barriers like, plastic sheets, hoods or canopies, plastic boxes and tents have come up. These barrier devices provided another layer of protection along with Personal Protective Equipment (PPE) (3).

Tseng JY and Lai HY from Taiwan were first to elaborate on aerosol box (4). The box was suggested as an additional layer of protection during endotracheal intubation, where exposure of HCWs to the virus in the form of aerosols is high. The aerosol box is a simple device and a basic version can be built with simple materials and tools (2),(4) (Table/Fig 1).

Kannaujia A et al., (1) conducted a similar study on manikin comparing two barrier enclosure methods (aerosol box and transparent sheets), whereas the current study is conducted during COVID-19 pandemic to assess the time required for successful intubation by experienced anaesthesiologists under two different barrier enclosures namely clear plastic sheets and aerosol boxes. Additionally, the time to intubate, first pass success rate, number of attempts, quality of laryngoscopy view, ease of tube insertion and Cormack Lehane scores were assessed in both groups (Table/Fig 2), (Table/Fig 3). At the same time, the difficulties encountered during intubation like laryngoscopy, glottic visualisation, arm movement restriction, ETT negotiation and stylet removal were studied in both the groups.

Material and Methods

This randomised controlled study was conducted in Parul Sevashram Hospital, Parul University, Vadodara, India from April 2021 to September 2021. A total of 50 patients were selected, who were admitted for elective surgery under general anaesthesia requiring endotracheal intubation. After obtaining Ethical Clearance (Ref. No: PUIECHR/PIMSR/00/081734/3104), the patients were divided randomly into two groups of 25 patients each.

Inclusion criteria: All patients requiring endotracheal intubation belonging to American Society of Anesthesiology (ASA) grade I and II posted for elective surgeries under general anaesthesia were included in the study

Exclusion criteria: Patients with anticipated difficult airway (Malampatti class III and IV), mouth opening <2 cm, obesity with BMI >30; patient tested positive for COVID-19 (RT-PCR), history of cervical spine injury/deformity, upper respiratory tract infections, pregnant and lactating female, patient having any cardiac disease or COPD, raised intracranial and intraocular pressure.

Sample size calculation: The study records from hospital were sought for the past one year. The data related to the total number of cases requiring general anaesthesia was computed.

Data was computed as under:

where
z is the z score (here z= 1.96)
ε is the margin of error 10%
pˆ is the population proportion 15%

(Total 512 surgeries were conducted under GA, of which 352 qualified the inclusion criteria)

Sample size (n) was calculated at confidence level (95%), z=1.96, population proportion p=15% as 53 subjects, thus rounding off to 50 subjects.

Study Procedure

A thorough preoperative assessment and explanation of the procedure was done. Routine investigations were done and written informed consent was taken. The patient was kept nil per orally. Data was collected on predesigned proforma for the present study. In the operation theatre, an intravenous line was secured and monitors like ECG, NIBP, SpO2 probe were applied. Baseline pulse, blood pressure, O2 saturation and respiratory rate were recorded.

Patients were randomly divided into two equal groups by an anesthesiologist using the sealed envelope method. Patients in group A were intubated with the aerosol box using macintosh laryngoscope patients in group B were intubated without aerosol boxes using a clear plastic sheet with macintosh laryngoscope (Table/Fig 2).

All the anesthesiologists involved in the study wore N95 masks, PPE and face shield. After explaining to the patients the aerosol box or clear plastic sheet was kept over the patient’s face. All patients were preoxygenated with 100% oxygen for five minutes. They were premedicated with intravenous Injection glycopyrrolate 4 μg/kg, Injection fentanyl 2 μg/kg, Injection ondansetron 0.1 mg/kg.

General anaesthesiawas induced with intravenous injection propofol 2-3 mg/kg and injection suxamethonium 2 mg/kg. Patients in both groups were intubated in classic sniffing position with 7.5 mm (Females) or 8 mm (Males) cuffed endotracheal tube.

Amongst the barrier devices, in group A the aerosol box was used. The aerosol box’s dimensions were 60×60×45 cm with 2 armholes in the head front and one inside panel of 10 cm in diameter. In group B, a clear plastic sheet was used, with prefabricated insulated slots for passage of the operator’s hands (Table/Fig 3), (Table/Fig 4). To increase protection, long sleeve gloves were fixed to each hole. All participants were familiarised with the devices before the commencement of the study.

Modified rapid sequence induction technique was used to avoid mask ventilation and to reduce aerosolisation in all the patients. A consultant anesthesiologist, with more than three years of experience, performed all intubations. After intubation, the cuff was inflated. The current placement of the endotracheal tube was confirmed by chest rise and by the presence of ETCO2. Bilateral air entry was checked and the endotracheal tube was fixed.

The following parameters were noted:

1. Time to intubate in seconds: 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.
2. Number of attempts required for successful intubation.
3. Quality of the laryngoscopy view (objectively defined as "percentage of glottic opening"/POGO) and ease of intubation: The percentage of glottic opening (POGO) score for laryngeal grading (5). The POGO score represents the distance from the anterior commissure to the inter arytenoid notch.
4. Cormack Lehane (CL) view (5).
5. Difficulty faced during intubation like during laryngoscopy, glottic visualisation, limitation of arm movement, endotracheal tube negotiation, stylet removal and fogging.

Maintenance was done with O2, N2O, sevoflurane inhalation and injection atracurium. After completion of the surgery, laryngoscopy and gentle suctioning was done. Neuromuscular blockade was reversed with intravenous injection glycopyrrolate 8 μg/kg and injection neostigmine 0.05 mg/kg. Patients were extubated after adequate muscle tone, the power achieved. Patients were then, shifted to the recovery room.

Failed tracheal intubation was defined as the time for intubating attempt of more than 60 seconds or oesophagal intubation. A drop in saturation to less than 92% or failure to intubate even after two attempts with direct laryngoscopy with aerosol box was considered as airway loss (6). Under both the circumstances, the aerosol box was removed and the patient was mask ventilated till saturation improved and intubation was attempted again without using the aerosol box (6).

Statistical Analysis

Statistical analysis was performed using Microsoft (MS) Excel spreadsheet. Age, weight, and gender of patients were presented as mean and Standard Deviations (SD) were compared among the groups using Chi-square test. Mann Whitney U tests were used to explore differences in non-normally distributed data . Student t-test was used to analyse the difference in mean. A p-value <0.05 was considered as statistically signifcant.

Results

Demographic data (age, weight, male female ratio) was comparable in both the groups (Table/Fig 5). Time to intubate was significantly less in group B (23.16 sec) as compared to group A (29.72 sec). Attempting successful intubation in 1st attempt was observed in 20 patients in group B as compared to 15 patients in group A . POGO score of 0-50 was observed in 5 patients in group A as compared to 2 patients in group B . Cormack Lehane grade 1 was observed in 16 patients of group A as compared to 19 patients of group B. (Table/Fig 6).

Rate of complications like sore throat and bleeding was less in group B as compared to group A (Table/Fig 7).

Incidence of encountering technical difficulties like difficulty during laryngoscopy, poor glottic visualisation, ETT negotiation and bougie manipulation were observed to a lesser extent in group B than group A.Fogging was observed in more number of patients in group B than group A (Table/Fig 8).

Haemodynamically, patients were comparable in both the groups (Table/Fig 9).

Discussion

Transmission of COVID-19 infection occurs through contact or droplet transmission which is increased during the aerosol-generating procedure, notable amongst which are laryngoscopy and intubation (7). Various apparatuses have been designed to provide safety to anaesthesiologists during airway procedures. Few innovations like clean plastic sheets, aerosol box, corrugated fibreboard were reported to restrict aerosolisation and droplet spray during intubation. However, these modified barrier devices, owing to their unfamiliarity can lead to impaired manual dexterity, faulty ergonomics, limited vision during ETT intubation thereby adversely affecting its success and have contamination and storage issues (1).

The present study compared the time to intubate (in seconds), ease of intubation, number of attempts, POGO scoring and Cormack Lehane grading among the two groups.

Time to intubate: In the present study, time required for intubation in the Aerosol box group (group A) was higher compared to the clear sheet group (group B). In this study, time for intubation (for aerosol box) is quite similar to the result of Kannaujia A et al., (1). But they have found lesser intubation time with aerosol box than plastic drape while using macintosh blade, which is in contrast with the present findings. Prolonged intubation time may be due to ergonomic limitation and restriction of manual dexterity. Venketeswaran M et al concluded that there was a non signifcant increase in time to intubate trend in patients with the use of an aerosol box. which was similar to the current study (8).

A recent study by Begley JL et al., described the significant challenges while intubating a mannequin when a barrier box was used (9). Similarly Feldman Oren et al., also concluded in their study that , paramedics wearing PPE can successfully perform endotracheal intubation using aerosol box but the intubation time may be prolonged (10). But Wakabayashi R et al., summarised that the effect of an aerosol box on tracheal intubation difficulty is not clinically relevant when experienced anaesthesiologist intubated the trachea in a normal airway condition (11).

Ease of intubation: The current study concluded that intubation in a patient with a clear plastic sheet (group B) was easier than aerosol box (group A). The hand movement, tube negotiation and stylet removal was easier in group B as compared to group A. Participant’s feedback in Kannaujia A et al., summarised that the hand movement restriction was more with aerosol box but it was free with plastic drape. They also found difficulty with stylet removal in three participants with arosol box whereas five participants complained about glaring under plastic drape which is not found in our study (1).

Brown H et al., observed that the rigid arm openings of the aerosol box restricted the insertion angle and superior caudal adjustment with the laryngoscope making the intubation environment unsuitable (12).

Many barrier devices (like plastic sheets, tents and aerosol boxes) have been used to decrease the spread of virus laden particles by containing the same within an enclosure. Such devices can be ergonomically restrictive due to the limited space available, affecting the anaesthesiologists’ manual dexterity. These barrier devices also curb optimisation manoeuvres like external laryngeal manipulation, lip traction or stylet introduction. These factors along with unfamiliarity with the device and visualisation difficulties often make endotracheal intubations difficult. Although promoted for safety, the degree to which these barrier devices compromise easy and successful intubation and their limitations have not been elucidated (1).

Number of attempts: In present study it was technically easier for the anaesthesiologists to intubate the patients without aerosol box. In the present study, the glottic visualisation was technically easier in group B than group A. In a study, the aerosol box significantly prolonged the time for successful intubation and decreased POGO score when using a direct laryngoscope (7). Similarly Cormack lehane grading in group B was more than in group A, suggesting better airway visualisation without aerosol box. In another study, the first attempt success was 77.8% in the DL group (direct laryngoscopy) while it was 66.7% in the Box DL group (direct laryngoscopy with aerosol box) which is similar to our study (8). A Canadian manikin-based simulation study reported that the meantime to intubation in a difficult airway scenario was increased with an aerosol box compared to without it (34.4s vs 27.3s, mean difference 7.1%) (13).

The Intubation Aerosol Containment System (IACS) with integrated sleeves and plastic drape provided an adequate protection from aerosolised particles (3). But aerosol boxes are heavy and bulky to carry and it is also difficult to position during emergency. It makes additional manipulation and rescue mask ventilation difficult in between intubtion attempts. The aerosol box becomes contaminated after use so it needs proper handling and sterilisation to prevent cross infection. In contrast to this plastic sheets are cheap, disposable, provide adequate visualisation and easy to do any manoeuvre during intubation. Plastic sheets also provides multiple access points to assistant. Matava CT et al., stated that low cost clear plastic sheets significantly limit aerosolisation and it is proved by using fluroscent resin powder with UV light detection in a dark room (14).

Complications: No major side-effects were noted in either of the groups in this study. However, the incidence of sore throat and bleeding was higher in the group A than group B.

Limitation(s)

Only intubating conditions were studied in patient with normal airway, but certain other airway procedures also need to be studied, like bag and mask ventilation, supraglottic airway device insertion, fiberoptic intubation and patients with difficult airway.

Conclusion

In the COVID-19 era, where intubation poses a high risk of transmission to the healthcare, both clear plastic sheets and aerosol box are a definitive barrier measures for airway management to prevent the anaesthesiologists from the aerosol transmission. Though airway management with clear plastic sheet was easier than aerosol box. At the same time, difficulty arises in handling airway, ETT negotiation, stylet, bougie manipulation, glaring which may be handled better with the familiar technique of conventional intubation (without aerosol box or clear plastic sheet).

References

1.
Kannaujia A, Haldar R, Shamim R, Mishra P, Agarwal A. Comparative evaluation of intubation performances using two different barrier devices used in the COVID-19 era: A manikin based pilot study. Saudi J Anaesth. 2021;15(2):86-92. [crossref] [PubMed]
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Maniar A, Jagannathan B. The aerosol box. J Anaesthesiol Clin Pharmacol. 2020;36(Suppl 1):S141-S143. [crossref] [PubMed]
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Gore RK, Saldana C, Wright DW, Klein AM. Intubation Containment System for Improved Protection From Aerosolized Particles During Airway Management. IEEE J Transl Eng Health Med. 2020;8:1600103. [crossref] [PubMed]
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Tseng JY, Lai HY. Protecting against COVID-19 aerosol infection during intubation. J Chin Med Assoc. 2020;83(6):582. [crossref] [PubMed]
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Reddy RM, Adke M, Patil P, Kosheleva I, Ridley S. Anaesthetic Department at Glan Clwyd Hospital. Comparison of glottic views and intubation times in the supine and 25 degree back-up positions. BMC Anesthesiol. 2016;16(1):113. [crossref] [PubMed]
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Puthenveettil N, Rahman S, Vijayaraghavan S, Suresh S, Kadapamannil D, Paul J. Comparison of aerosol box intubation with C-MAC video laryngoscope and direct laryngoscopy- A randomised controlled trial. Indian J Anaesth. 2021;65(2):133-38. [crossref] [PubMed]
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World Health Organization, Pandemic and Epidemic Diseases, World Health Organization. Infection prevention and control of epidemic- and pandemic-prone acute respiratory infections in health care: WHO guidelines. [Internet]. 2014 [cited 2021 Jul 20]. Available from: http://apps.who.int/iris/bitstream/10665/112656/1/9789241507134_eng.pdf?ua=1
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Venketeswaran M, Srinivasaraghavan N, Balakrishnan K, Seshadri R, Sriman S. Intubation outcomes using the aerosol box during the COVID-19 pandemic: A prospective, observational study. Indian J Anaesth. 2021;65(3):221-28. [crossref] [PubMed]
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Begley JL, Lavery KE, Nickson CP, Brewster DJ. The aerosol box for intubation in coronavirus disease 2019 patients: An in-situ simulation crossover study. Anaesthesia. 2020;75(8):1014-21. [crossref] [PubMed]
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Feldman O, Samuel N, Kvatinsky N, Idelman R, Diamand R, Shavit I. Endotracheal intubation of COVID-19 patients by paramedics using a box barrier: A randomized crossover manikin study. El-Tahan MR, editor. PLoS One. 2021;16(3):e0248383. [crossref] [PubMed]
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Wakabayashi R, Ishida T, Yamada T, Kawamata M. Effect of an aerosol box on tracheal intubation difficulty. J Anesth. 2020;34(5):790-93. [crossref] [PubMed]
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Brown H, Preston D, Bhoja R. Thinking Outside the Box: A Low-cost and Pragmatic Alternative to Aerosol Boxes for Endotracheal Intubation of COVID-19 Patients. Anesthesiology. 2020;133(3):683-84. [crossref] [PubMed]
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Fong S, Li E, Violato E, Reid A, Gu Y. Impact of aerosol box on intubation during COVID-19: a simulation study of normal and difficult airways. Can J Anaesth J Can Anesth. 2021;68(4):496-504. [crossref] [PubMed]
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Matava CT, Yu J, Denning S. Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19. Can J Anaesth J Can Anesth. 2020;67(7):902-04. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/56601.16454

Date of Submission: Mar 24, 2022
Date of Peer Review: Apr 23, 2022
Date of Acceptance: May 10, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 01, 2022
• Manual Googling: May 03, 2022
• iThenticate Software: May 19, 2022 (23%)

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