Device with camera in orotracheal intubation training: possibility of medical education a pandemic period

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


INTRODUCTION
Orotracheal intubation is one of the most important procedures in airway management.It provides adequate oxygenation and ventilation for patients and ensures airway protection 1 .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 complications 2,3 .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 procedure 4,5 .
It is estimated that approximately 3% of patients with COVID-19 will require orotracheal intubation at some point during the course of the disease 6 .In Brazil, a study reports that 4 of 10 patients with indication for hospitalization required a definitive airway with mechanical ventilation 7 .The Brazilian Association of Intensive Medicine (AMIB, Associação de Medicina Intensiva Brasileira) recommends the use of a videolaryngoscope to facilitate the intubation technique 4 , 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 procedure 8 .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 laryngoscopy 9 .
Therefore, video-assisted intubation training can bring positive results to medical education, since it facilitates learning about airway access 10 .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 (videoassisted) 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 Macintoshtype 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  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.

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 Chart 1. Device assembly guidelines.
Use hot glue to affix the largest axis camera (Wifi wireless endoscope) to the metallic blade.
• Make sure the camera's horizon is adjusted before carrying out the procedure.
Bend the short arm of the metal blade in an "L" shape encircling the camera.
• This aids in camera horizon stability.
Insert the double-face adhesive tapes in the lower region of the metallic blade.
The metallic blade will shape the laryngoscope blade (curved or linear), the adhesives facilitate the removal and adjustments.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).

DISCUSSION
Adequate airway management is a factor that can save lives; for it to be successful, the health professional must have
the step-by-step diagram in Chart 1).It can be used on any laryngoscope blade, regardless of the number.
Adapt the handcrafted device to the laryngoscope, distancing 2cm from the distal end of the laryngoscope.The plastic tape helps fixing the optical fiber to the laryngoscope handle.
adequate mastery of the laryngoscopy technique and know how to deal with factors that increase the procedure complexity, such as environmental factors and patient profile3 .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 intubations 11 .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 laryngoscopy 12 .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 mortality13 .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 training14 .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.CONCLUSIONSThe 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.