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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 65-69

The use of USB endoscope (borescope) to guide nasal tracheal intubation: a pilot study


1 Department of Anesthesiology and Surgical Intensive Care, Alexandria University Hospitals, Alexandria, Egypt
2 Department of Anesthesiology and Surgical Intensive Care, Alexandria University Hospitals, Alexandria; Department of Anesthetics, Harrogate and District NHS Foundation Trust, Harrogate, UK, Egypt

Date of Submission24-Oct-2018
Date of Acceptance22-Aug-2019
Date of Web Publication16-Apr-2020

Correspondence Address:
MBBCh, MSc, FRCPC, MD, ABPM Mohammad H.I Ahmad Sabry
Department of Anesthesiology and Surgical Intensive Care, Khartoum Square, Shalalat, Alexandria 21111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_86_18

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  Abstract 

Background In spite of the presence of multiple videolaryngoscopes in the market, financial restrains prevent their routine use in many clinical practices.
Patients and methods The endoscope USB camera was inserted in a conventional endotracheal tube which could be inserted nasally (6.5 or 7 cuffed endotracheal tube). Sterile K-Y lubricating gel was used to facilitate the insertion of the borescope. This was used for nasal intubated in eight patients.
Results Nasal intubation trials were done by an experienced physician for eight patients. All eight patients were Mallampati class 1 or 2. One patient was intubated at the first attempt, three were intubated at the second attempt, and one was intubated at the third attempt. There was failure in three cases (secretions and blood).
Conclusion Borescope can be used as a cheap option for nasal airway management. Randomized studies need to be done for its evaluation compared with other videolaryngoscopy devices.

Keywords: borescope, optical stylets, tracheal intubation, videolaryngoscope


How to cite this article:
Ahmad Sabry MH, Aboughazy AM. The use of USB endoscope (borescope) to guide nasal tracheal intubation: a pilot study. Res Opin Anesth Intensive Care 2020;7:65-9

How to cite this URL:
Ahmad Sabry MH, Aboughazy AM. The use of USB endoscope (borescope) to guide nasal tracheal intubation: a pilot study. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 May 31];7:65-9. Available from: http://www.roaic.eg.net/text.asp?2020/7/1/65/282595


  Introduction Top


Difficult airway is still a challenge for anesthesiologist in many situations. Videolaryngoscopes are present as advancement in airway management. In spite of the presence of multiple videolaryngoscopes in the market, financial restrains prevent their routine use in many clinical practices.

The aim of this study was to evaluate a cheap option for videolaryngoscopy by using USB endoscope (borescope) to guide nasal tracheal intubation when integrated with an iPhone, iPad, or android device.


  Patients and methods Top


After approval of the Ethics Committee of Faculty of Medicine, Alexandria University, we experimented the use of USB endoscope (borescope) in eight patients as a pilot study to evaluate the feasibility to use it as a method of nasal airway management. The borescope is not labeled for the medical use, and the product is still investigational in the field of airway.

Patient preparation

All patients were premedicated with midazolam 0.03 mg/kg, intravenously, and atropine 0.02 mg/kg, intravenously.

Anesthetic technique

  1. On arrival to the operating room, the anesthetic procedure was initiated.
  2. The intubation procedure was carefully explained to the patient.
  3. Each patient was attached with the following:
    1. Multichannel monitor (Infinity; Dräger, Lübeck, Germany) for the continuous display of the following:
      1. ECG monitoring (lead ІІ) for detection of dysrhythmias.
      2. Noninvasive arterial blood pressure ‘NIBP’ in mmHg.
      3. Heart rate (beats/min).
      4. Peripheral oxygen saturation (SpO2%).
    2. Nerve stimulator (Microstim DB3; Viamed, UK) to monitor the neuromuscular function every 20 min.
      1. A 20-G cannula is inserted.
      2. Preoxygenation of the patient was done for 3 min with 100% oxygen.
      3. Induction was done with fentanyl 1 μg/kg and propofol 2 mg/kg.
      4. Orotracheal intubation was facilitated by cisatracurium 0.2 mg/kg.
      5. Nasotracheal intubation was done using the borescope device, having it lubricated using sterile K-Y gel and inserted in the endotracheal tube size 7. This was done after ensuring full muscle relaxation as assessed by nerve stimulator on fading of the four twitches of train-of-four monitor.


The USB borescope snake endoscope is a lightweight, cheap, practical, integrated device that can be used in endotracheal intubation. The USB borescope does not need any special preparations or equipment and could be used anywhere by the anesthetist as long as he/she carries his/her smart phone, iPad, or android device.

The main idea of this study is to introduce a new, effective, cheap, and practical alternative for videolaryngoscopy [1]. There are several manufacturing companies for the USB borescope. The USB Borescope Snake Inspection Endoscope Tube (Borescope, Shanghai, China) 5.5 mm Camera is a portable, handheld video endoscope system with a flexible insertion tube (present in different lengths from 0.5 to 5 meters. The USB borescope was used initially in industrial purposes. It can easily be operated by plugging directly into the personal computer, laptop, android phone, or iPhone via the USB port. The high-resolution camera provides good video quality, and with adjustable LED lights on the tip, you can see clearly in dark areas. The camera head and cable are water resistant (IP67), which makes it possible to work in multiple environments and to be properly sterilized. It can also capture pictures or record videos through the computer, laptop, or cell phone (Apple IOS or android) ([Figure 1]) easily with the bundled software and is capable of taking snapshots and recording videos for educative and medico-legal purposes. This device could be used in airway visualization and intubation in many ways; it could be attached to the blade of the conventional curved McIntosh (Arabic manufacturer, Helwan, Egypt) laryngoscope using sterile adhesive tape and help visually guide the insertion of the endotracheal tube via direct laryngoscopy. Another method to use it is to insert it in an Endoflex tube with adjustable tip, and the tube could be inserted orally or nasally without laryngoscopy and the tip could be adjusted under vision, until a clear view of the glottis could be obtained on the cell phone screen. The third method (which is the method used in this study) is the simplest of all and does not need laryngoscopy or any special endotracheal tubes or equipment. The endoscope USB camera can be inserted in a conventional endotracheal tube, which could be inserted nasally (7 or 6.5 cuffed endotracheal tube); sterile K-Y gel was used to facilitate the insertion of the borescope.
Figure 1 The borescope connected to an iPhone.

Click here to view


Manual manipulation of the neck and elevation of the mandible during intubation make the visualization easier, probably owing to opening the airway, avoiding the collapse of soft tissue that may obscure the view.

The use of borescope for initial nasal intubation trials for eight patients was evaluated by an experienced anesthesiologist (>20 years of experience).

The secretion and blood were the main failure causes for intubation, as this obscures the view, and the use of local nasal decongestant and drying agent (atropine) about 30 min before intubation helped to increase success of intubation.

Intubation trial was done by an experienced anesthesiologist (>10 years of practice). Only three attempts were allowed for no more than 60 s or start of desaturation. Oxygenation between trials was done for 30 s or till the saturation reach the baseline.


  Results Top


All the eight intubated patients were Mallampati class 1 or 2.

One patient was intubated at the first attempt, three were intubated at the second attempt, one was intubated at the third attempt, and three failed.

The images were comparable to other videolaryngoscopy devices ([Figure 2],[Figure 3],[Figure 4],[Figure 5]).
Figure 2 The laryngeal opening viewed by the borescope; image captured with the iPhone.

Click here to view
Figure 3 The laryngeal opening viewed by the borescope; image captured with the iPhone after redirection of the tube with stylet inside.

Click here to view
Figure 4 Trachea viewed by the borescope; image captured with the iPhone.

Click here to view
Figure 5 Right bronchus viewed by the borescope; image captured with the iPhone.

Click here to view


We failed to record a movie on the intubation probably owing to the need of a special program or incompatibility with the iPhone or android device. No difference in the image quality was recognized between the Apple IOS and android used.

No complication was encountered in our patients other than mild sore throat postoperatively, which may be related to the endotracheal tube itself, than the borescope.


  Discussion Top


This trial was the first to use borescope on patients. Borescope had been used before as a cheap tool to train physicians on videolaryngoscopy [1].

Using manikin training was found to be superior than no training at all in a meta-analysis [2].

It being water resistance encouraged us to use the same protocol for sterilization as the one used for sterilization of fiberoptic airway endoscopy.

It being cheap may also give in the future a single-use option. In spite of using disposable equipment in airway management, they were found to be more expensive than using reusable ones in two institutes in USA and Denmark [3],[4]; however, the cost of the scope was less than 10% than the price of single intonation in these two studies. Videolaryngoscopy is still not present in all clinical locations, and there is a need for it even in some developed countries [5]. The potential cost savings are certainly attractive, although some of this price difference reflects the cost of getting medical devices approved for human use and to the market, owing to the regulatory framework that surrounds the devices. Still the low cost can make it useful as a training tool on manikin if the process of human use approval was not possible [1].

The size of the borescope restricts its use for adult intubation only, as it is 5.5 mm in diameter which is suitable to be inserted along with stylet in at least 7-mm endotracheal tube.

Vivasight is a tube embedded with a camera at the tube tip that is used for tracheal intubation [6]; however, it needs the use of light source, and it is more expensive compared with the borescope, which can be used with the iPhone or android instead.In the eight patients who underwent the procedure using borescope, we had 62.5% success rate, which was less than success rate in videolaryngoscope studies [7]. Time to intubate was not measured, and this was considered as limitation of the study. When used in human subjects, we limited the trial to one minute or desaturation; however, no desaturation occurred, as we did preoxygenation before the attempt.

The device has not been approved for use in humans, and there have been no testing regarding issues such as ensuring the materials used in its manufacture are biologically inert and that it is resistant to breakage within the airway.

In this study, we use the same protocol for the sterilization that is used for the fiberoptic intubation device; however, its efficacy was not confirmed with microbiological evidence studies.

Considering the fact that borescope has not been licensed for medical use at the moment, in only very limited cases when no other airway devices are available, this innovative way of tracheal intubation may be justified.


  Conclusion Top


Borescope can be used as a cheap option for airway management and its training. Randomized studies need to be done for its evaluation compared with other videolaryngoscopy devices.

Acknowledgements

Mohammad H.I. Ahmad Sabry contributed toward idea, practical part, and writing. Ahmed M. Aboughazy contributed toward idea, practical part, and writing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Trivedi JN. An economical model for mastering the art of intubation with different video laryngoscopes. Indian J Anaesth 2014; 58:394.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Kennedy CC, Cannon EK, Warner DO, Cook DA. Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Crit Care Med 2014; 42:169–178.  Back to cited text no. 2
    
3.
Gupta D, Wang H. Cost-effectiveness analysis of flexible optical scopes for tracheal intubation: a descriptive comparative study of reusable and single-use scopes. J Clin Anesth 2011; 23:632–635.  Back to cited text no. 3
    
4.
Tvede MF, Kristensen MS, Nyhus-Andreasen M. A cost analysis of reusable and disposable flexible optical scopes for intubation. Acta Anaesthesiol Scand 2012; 56:577–584.  Back to cited text no. 4
    
5.
Cook TM, Kelly FE. A national survey of videolaryngoscopy in the United Kingdom. Br J Anaesth 2017; 118:593–600.  Back to cited text no. 5
    
6.
Huitink JM, Koopman EM, Bouwman RA, Craenen A, Verwoert M, Krage R et al. Tracheal intubation with a camera embedded in the tube tip (Vivasight™). Anaesthesia 2013; 68:74–78.  Back to cited text no. 6
    
7.
Vargas M, Pastore A, Aloj F, Laffey JG, Servillo G. A comparison of videolaryngoscopes for tracheal intubation in predicted difficult airway: a feasibility study. BMC Anesthesiol 2017; 17:25.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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Introduction
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