Plastic Sheet and Video Intubating Stylet: A Technical Note.

Received: 3 July 2021; Received in revised form: 14 July 2021; Accepted: 23 July 2021. Corresponding Author: Hsiang-Ning Luk, MD, MS, PhD, Department of Anesthesia, Hualien Tzu-Chi Medical Center, No. 707, Sec. 3, Zhongyang Rd., Hualien City, Hualien County 970473, Taiwan (lukairforce@gmail.com). This is a technical note for tracheal intubators for performing tracheal intubation during the COVID-19 pandemic and beyond. Up until July 2, 2021, there have been 182,319,261 confirmed cases and 3,954,324 deaths. Unfortunately, it has been estimated that thousands of healthcare workers have died from the disease. It is not easy to know exactly how many airway managers contracted COVID-19 while fulfilling their vital duties of airway management during the pandemic. All the relevant principles have been referenced in all available consensus guidelines for airway management in patients with COVID-19. However, the scarcity of medical resources and exhausted capacity in the real world might require alternative strategies at the scene. We need to fi nd an affordable, accessible and available strategy to accomplish the goals of tracheal intubation during the pandemic (e.g., safe, accurate, and smooth). Here, we present our experiences of applying a plastic sheet as an ancillary physical barrier against contagious droplets and secretions from the patient’s airway in Taiwan. Meanwhile, we use a video-assisted intubating stylet technique to perform tracheal intubation. A brief description of how to prepare such a plastic sheet is shown in Figure 1, and how to apply it with various intubating tools is shown in Figure 2. First, we prepared a transparent and soft plastic sheet (e.g., excised from a plastic trash bag made of ethylene vinyl acetate, 0.05–0.10 mm in thickness; 50 × 80 cm in size). We marked two small areas on the plastic sheet (Figure 1A) and cut a small cross with a surgical blade in the center of each marked area (Figure 1B). Then, we covered the marked area with a small transparent adhesive fi lm dressing (e.g., Tegaderm, Figure 1C). Finally, we used a large bore needle to make a small nick at the center of the cross on each fi lm (Figure 1D). Then, it was ready for applying intubating tools, shown in Figure 2. If the intubating stylet technique was preferred (Figure 2A and 2B), one hole was used for passage of the stylet, and the other hole was for various suction tubes. On the other hand, if video laryngoscopy was the preference, one hole was used to introduce the laryngoscope, and the other hole was for passing the endotracheal tube (Figure 2C ad 2D). During the laryngoscope setup, in order not to damage the adhesive fi lm, which functions to minimize the defect in the plastic sheet and to prevent contamination from the patient, we recommend the following technique. First, the laryngoscope camera module is inserted through the hole (Figure 2C). Then, the disposable blade is mounted over the module from the inner side of the sheet (Figure 2D). In this way, the adhesive Tegaderm fi lm is kept intact. After the endotracheal tube is introduced into the trachea, the plastic sheet is carefully removed in order to prevent further contamination. With this goal in mind, we tear the plastic sheet along the readymade seam line (Figure 3A), until reaching the perimeter of the hole for entry of the endotracheal tube (Figure 3B). In this way, we are able to remove the plastic sheet while leaving the endotracheal tube in a secured position. For a home-made plastic sheet, we