Sheet Barrier and Intubating Stylet

Round 1

Reviewer 1 Report

I reviewed the manuscript entitled "Sheet Barrier and Intubating Stylet" by Tsai and Luk, submitted to Encyclopedia (#encyclopedia-1376029). Thorough this Entry, the authors tried to update our knowledge about the personal protective equipment (PPE), barrier systems, and the video intubating stylet during the COVID-19 pandemic. The authors rigorously summarized the latest findings of abovementioned device when performing aerosol generating medical procedures (AGMP), which I found an interesting topic. However, I have several concerns regarding this manuscript. My comments are listed below:

1

The title should be more specific and objective. The one suggested example is "Sheet Barrier and Intubating Stylet in the era of COVID-19 pandemic".

2

In terms of style and structure, this paper does not conform to the journal guidelines (https://www.mdpi.com/journal/encyclopedia/instructions). Please read the instruction for the authors carefully. The reviewer thinks Author Biography is the welcome addition to ensure the reliability of this entry contents.

3

The quality of some of the photos in the paper is extremely poor and too small. Please try to improve the magnification and size of each figure.

4

Supplementary video file, which attached in this manuscript, is not cited in the manuscript text.

5

This review paper is significantly overlapping with the another review paper written by the same group [1]. This is the significant problem and need to be amended. Especially, the reviewer found several photos such as Figure 9 are exactly the same or similar with one that appears above mentioned paper [1]. Please note, this is not acceptable research practice.

6

According to the previous literature [2-11], intubating stylet is not commonly used in the emergency department (ED). What is the merit and advantage for using intubating stylet, rather than using other types of video laryngoscope ED during the COVID-19 pandemic? Please make this point clear.

What should we do, if intubating stylet is not equipped in the ED? Based on these couple of literature [2-11], the reviewer speculates vast majority ED do not have intubating stylet. In addition, current consensus guidelines for managing the airway in patients with COVID-19 [12, your cited reference 30] does not specify the type of video laryngoscope. The description appears in page 4 needed to be expanded and be rectified.

7

The authors mention that "potential benefits of the intubating stylet include a small profile, which results in less overall patient airway manipulation, such as less opening of the mouth and less lifting of the tongue." in their manuscript. The reviewer thinks gum-elastic bougie (GEB) has the same advantage. Recent paper clearly delineate the usefulness of GEB [13-16]. The authors should cite these references [13-16] in this manuscript, and briefly discuss the usefulness of GEB during the COVID19 pandemic. In fact, current consensus guidelines for managing the airway in patients with COVID-19 [12] also recommend equipping GEB (Figure 5, Exemplar of kit dump mat for COVID-19).

In conclusion, although this is the interesting topic, this manuscript has several issues that should be amended. Especially, the author should consider the abovementioned points 5 to 7. I look forward to reading revised version of the manuscript.

References

1. Luk HN, Yang YL, Huang CH, Su IM, Tsai PB. Application of Plastic Sheet Barrier and Video Intubating Stylet to Protect Tracheal Intubators During Coronavirus Disease 2019 Pandemic: A Taiwan Experience. Cell Transplant. 2021 Jan-Dec;30:963689720987527. doi: 10.1177/0963689720987527. Erratum in: Cell Transplant. 2021 Jan-Dec;30:9636897211027078. PMID: 33426911; PMCID: PMC7804358.
2. Morton T, Brady S, Clancy M. Difficult airway equipment in English emergency departments. Anaesthesia. 2000 May;55(5):485-8. doi: 10.1046/j.1365-2044.2000.01362.x. PMID: 10792145.
3. Walsh K, Cummins F. Difficult airway equipment in departments of emergency medicine in Ireland: results of a national survey. Eur J Anaesthesiol. 2004 Feb;21(2):128-31. doi: 10.1017/s026502150400208x. PMID: 14977344.
4. Levitan RM, Kush S, Hollander JE. Devices for difficult airway management in academic emergency departments: results of a national survey. Ann Emerg Med. 1999 Jun;33(6):694-8. PMID: 10339685.
5. Ono Y, Tanigawa K, Shinohara K, Yano T, Sorimachi K, Inokuchi R, Shimada J. Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study. Int J Emerg Med. 2017 Sep 13;10(1):28. doi: 10.1186/s12245-017-0155-6. PMID: 28905252; PMCID: PMC5597568.
6. Deiorio NM. Continuous end-tidal carbon dioxide monitoring for confirmation of endotracheal tube placement is neither widely available nor consistently applied by emergency physicians. Emerg Med J. 2005 Jul;22(7):490-3. doi: 10.1136/emj.2004.015818. PMID: 15983084; PMCID: PMC1726849.
7. Swaminathan AK, Berkowitz R, Baker A, Spyres M. Do emergency medicine residents receive appropriate video laryngoscopy training? A survey to compare the utilization of video laryngoscopy devices in emergency medicine residency programs and community emergency departments. J Emerg Med. 2015 May;48(5):613-9. doi: 10.1016/j.jemermed.2014.12.029. Epub 2015 Jan 31. PMID: 25648052.
8. Browne A. A lack of anaesthetic clinical attachments for emergency medicine advanced trainees in New Zealand: perceptions of directors of emergency medicine training. N Z Med J. 2015 Aug 7;128(1419):45-9. PMID: 26365845.
9. Langhan ML, Chen L. Current utilization of continuous end-tidal carbon dioxide monitoring in pediatric emergency departments. Pediatr Emerg Care. 2008 Apr;24(4):211-3. doi: 10.1097/PEC.0b013e31816a8d31. PMID: 18431217.
10. Losek JD, Olson LR, Dobson JV, Glaeser PW. Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors. Pediatr Emerg Care. 2008 May;24(5):294-9. doi: 10.1097/PEC.0b013e31816ecbd4. PMID: 18496112.
11. Reeder TJ, Brown CK, Norris DL. Managing the difficult airway: a survey of residency directors and a call for change. J Emerg Med. 2005 May;28(4):473-8. doi: 10.1016/j.jemermed.2004.11.027. PMID: 15837035.
12. 12 Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020 Jun;75(6):785-799. doi: 10.1111/anae.15054. Epub 2020 Apr 1. PMID: 32221970; PMCID: PMC7383579.
13. Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med. 2017 Oct;70(4):473-478.e1. doi: 10.1016/j.annemergmed.2017.04.033. PMID: 28601269.
14. Ono Y, Shinohara K, Shimada J, Inoue S, Kotani J. Lower maximum forces on oral structures when using gum-elastic bougie than when using endotracheal tube and stylet during both direct and indirect laryngoscopy by novices: a crossover study using a high-fidelity simulator. BMC Emerg Med. 2020 May 6;20(1):34. doi: 10.1186/s12873-020-00328-9. PMID: 32375651; PMCID: PMC7201614.
15. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496. PMID: 29800096; PMCID: PMC6134434.
16. Combes X, Jabre P, Margenet A, Merle JC, Leroux B, Dru M, Lecarpentier E, Dhonneur G. Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm. Anesthesiology. 2011 Jan;114(1):105-10. doi: 10.1097/ALN.0b013e318201c42e. PMID: 21169803.

Author Response

Response to the Reviewer 1:

I reviewed the manuscript entitled "Sheet Barrier and Intubating Stylet" by Tsai and Luk, submitted to Encyclopedia (#encyclopedia-1376029). Thorough this Entry, the authors tried to update our knowledge about the personal protective equipment (PPE), barrier systems, and the video intubating stylet during the COVID-19 pandemic. The authors rigorously summarized the latest findings of abovementioned device when performing aerosol generating medical procedures (AGMP), which I found an interesting topic. However, I have several concerns regarding this manuscript. My comments are listed below:

A 1: The title should be more specific and objective. The one suggested example is "Sheet Barrier and Intubating Stylet in the era of COVID-19 pandemic".

Q 1: Thanks for the reviewer’s fair and constructive comments and expert opinions. The authors really appreciate it.

The short title of this entry paper “Sheet barrier and intubating stylet ” is limited to no more than 5 words, required by the Journal’s policy. The authors understand the short title itself might not express clearly the relationship to the COVID-19 situation. Hopefully, the readers could shortly catch the point in the Introduction paragraph and find the messages in the article making sense and useful.

A 2: In terms of style and structure, this paper does not conform to the journal guidelines (https://www.mdpi.com/journal/encyclopedia/instructions). Please read the instruction for the authors carefully. The reviewer thinks Author Biography is the welcome addition to ensure the reliability of this entry contents.

Q 2: The authors appreciate the reviewer’s reminding on this issue and will check it out according to the instructions for authors.

Q 3: The quality of some of the photos in the paper is extremely poor and too small. Please try to improve the magnification and size of each figure.

A 3: The photos, required by the instruction, were inserted to the text in the manuscript is for later printing process. The figures were attached as JPEG files during the submission process. Nevertheless, the authors have re-pasted the magnified figures in the revised manuscript for review.

Q 4: Supplementary video file, which attached in this manuscript, is not cited in the manuscript text.

A 4: The error has been corrected. The video clip for demonstration has been cited in the legend of the Figure 6.

Q 5: This review paper is significantly overlapping with the another review paper written by the same group [1]. This is the significant problem and need to be amended. Especially, the reviewer found several photos such as Figure 9 are exactly the same or similar with one that appears above mentioned paper [1]. Please note, this is not acceptable research practice.

A 5: The authors appreciate the reviewer’s kind concerns and reminding the research ethics issues. While the research ethics and conducts involve plagiarism, falsification and fabrication, the authors are also fully aware that publication misconduct such as duplication and redundant publication.

However, this entry paper serves as a concept and review paper which deals with a novel idea and practice. Using plastic sheet barrier and video intubating stylet technique for tracheal intubation during COVID-19 pandemic and possibly beyond is a brand new thought. The authors so far have published one communication in Anesthesia and Analgesia, one review article in Cell Transplantation, and one short technical note in Asian Journal of Anesthesiology. The authors have no intention for duplication of publication. Instead, the authors continue to advocate this idea with different context in the review article for broader readers who might be interesting at this particular clinical issue.

Before the authors submitted this manuscript to Encyclopedia as an entry paper, the written permission to reproduce some photos has been obtained from the relevant publishers (e.g., Cell Transplantation, Asian Journal of Anesthesiology). Therefore, it is not unethical to reproduce or modify some photos from previously published materials.

Therefore, the authors are also diligent preparing any figures in this manuscript and try to pass important concept and notion and hope the readers who might not have the chance to read our prior publications. The authors responsibly cited the source of reproduced figures from previously published materials (please see the relevant figure legends).

Q 6:  According to the previous literature [2-11], intubating stylet is not commonly used in the emergency department (ED). What is the merit and advantage for using intubating stylet, rather than using other types of video laryngoscope ED during the COVID-19 pandemic? Please make this point clear. What should we do, if intubating stylet is not equipped in the ED? Based on these couple of literature [2-11], the reviewer speculates vast majority ED do not have intubating stylet. In addition, current consensus guidelines for managing the airway in patients with COVID-19 [12, your cited reference 30] does not specify the type of video laryngoscope. The description appears in page 4 needed to be expanded and be rectified.

A 6: The authors appreciate the reviewer’s comments on airway management tools in the ER.

Indeed, video intubating stylet technique is not prevalent in many countries and regions. However, such intubating technique is overwhelmingly adopted and familiarized in Taiwan and some Southeast Asian countries. In Taiwan, such technique is not only prevailed in the department of anesthesia, but also in the department of emergency medicine, intensive care unit and ordinary wards. The authors believe there is a new trend that video intubating stylet technique will prevail in the airway management, if people in this field really have the chance to know it and willing to try it.

The authors acknowledge the role of video laryngoscopy, particular during the COVID-19 pandemic. As many experts state in the relevant guidelines that the airway managers should adopt the modality they are familiar with to intubate the patients during COVID-19 pandemic. For those who have no video intubating stylet equipped, then (conventional and video) laryngoscopy is the only choice. But that is exactly the purpose that the authors wish to provide and share an insight regarding the role of video intubating stylet technique with the colleagues.

If the colleagues had to use videolaryngoscopy technique during CIVUD-19 pandemic, the plastic sheet barrier also serves the purpose under this condition. The technique note in the references 39 and 40 clearly illustrate such possibility.

Q 7:  The authors mention that "potential benefits of the intubating stylet include a small profile, which results in less overall patient airway manipulation, such as less opening of the mouth and less lifting of the tongue." in their manuscript. The reviewer thinks gum-elastic bougie (GEB) has the same advantage. Recent paper clearly delineate the usefulness of GEB [13-16]. The authors should cite these references [13-16] in this manuscript, and briefly discuss the usefulness of GEB during the COVID19 pandemic. In fact, current consensus guidelines for managing the airway in patients with COVID-19 [12] also recommend equipping GEB (Figure 5, Exemplar of kit dump mat for COVID-19).

A 7: The authors appreciate the diligent works at GEB issue and providing relevant literatures for reference.       

The role of GEB for airway management has been added in the revised manuscript.

In conclusion, although this is the interesting topic, this manuscript has several issues that should be amended. Especially, the author should consider the abovementioned

points 5 to 7. I look forward to reading revised version of the manuscript.

References provided by the reviewer 1.

1. Luk HN, Yang YL, Huang CH, Su IM, Tsai PB. Application of Plastic Sheet Barrier and Video Intubating Stylet to Protect Tracheal Intubators During Coronavirus Disease 2019 Pandemic: A Taiwan Experience. Cell Transplant. 2021 Jan-Dec;30:963689720987527. doi:10.1177/0963689720987527. Erratum in: Cell Transplant.2021 Jan-Dec;30:9636897211027078. PMID: 33426911;PMCID: PMC7804358.
2. Morton T, Brady S, Clancy M. Difficult airway equipment in English emergency departments. Anaesthesia. 2000 May;55(5):485-8. doi: 10.1046/j.1365-2044.2000.01362.x. PMID: 10792145.
3. Walsh K, Cummins F. Difficult airway equipment in departments of emergency medicine in Ireland: results of a national survey. Eur J Anaesthesiol. 2004 Feb;21(2):128-31. doi: 10.1017/s026502150400208x. PMID: 14977344.
4. Levitan RM, Kush S, Hollander JE. Devices for difficult airway management in academic emergency departments: results of a national survey. Ann Emerg Med. 1999 Jun;33(6):694-8. PMID: 10339685.
5. Ono Y, Tanigawa K, Shinohara K, Yano T, Sorimachi K, Inokuchi R, Shimada J. Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study. Int J Emerg Med. 2017 Sep 13;10(1):28. doi: 10.1186/s12245-017-0155-6. PMID: 28905252; PMCID: PMC5597568.
6. Deiorio NM. Continuous end-tidal carbon dioxide monitoring for confirmation of endotracheal tube placement is neither widely available nor consistently applied by emergency physicians. Emerg Med J. 2005 Jul;22(7):490-3. doi:10.1136/emj.2004.015818. PMID: 15983084; PMCID:PMC1726849.
7. Swaminathan AK, Berkowitz R, Baker A, Spyres M. Do emergency medicine residents receive appropriate videolaryngoscopy training? A survey to compare the utilization of video laryngoscopy devices in emergency medicine residency programs and community emergency departments. J Emerg Med. 2015 May;48(5):613-9. doi:10.1016/j.jemermed.2014.12.029. Epub 2015 Jan 31. PMID:25648052.
8. Browne A. A lack of anaesthetic clinical attachments for emergency medicine advanced trainees in New Zealand:perceptions of directors of emergency medicine training. N Z Med J. 2015 Aug 7;128(1419):45-9. PMID: 26365845.
9. Langhan ML, Chen L. Current utilization of continuous end-tidal carbon dioxide monitoring in pediatric emergency departments. Pediatr Emerg Care. 2008 Apr;24(4):211-3. doi:10.1097/PEC.0b013e31816a8d31. PMID: 18431217.
10. Losek JD, Olson LR, Dobson JV, Glaeser PW. Tracheal intubation practice and maintaining skill competency: survey of pediatric emergency department medical directors. Pediatr Emerg Care. 2008 May;24(5):294-9. doi:10.1097/PEC.0b013e31816ecbd4. PMID: 18496112.
11. Reeder TJ, Brown CK, Norris DL. Managing the difficult airway: a survey of residency directors and a call for change. J Emerg Med. 2005 May;28(4):473-8. doi: 10.1016/j.jemermed.2004.11.027. PMID: 15837035.
12. Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anaesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of Anaesthetists. Anaesthesia. 2020 Jun;75(6):785-799. doi: 10.1111/anae.15054. Epub 2020 Apr 1. PMID:32221970; PMCID: PMC7383579.
13. Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med. 2017 Oct;70(4):473-478.e1. doi:10.1016/j.annemergmed.2017.04.033. PMID: 28601269.
14. Ono Y, Shinohara K, Shimada J, Inoue S, Kotani J. Lower maximum forces on oral structures when using gum-elastic bougie than when using endotracheal tube and stylet during both direct and indirect laryngoscopy by novices: a crossover study using a high-fidelity simulator. BMC Emerg Med. 2020 May 6;20(1):34. doi: 10.1186/s12873-020-00328-9. PMID:32375651; PMCID: PMC7201614.
15. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA. 2018 Jun 5;319(21):2179-2189. doi:10.1001/jama.2018.6496. PMID: 29800096; PMCID:PMC6134434.
16. Combes X, Jabre P, Margenet A, Merle JC, Leroux B, Dru M, Lecarpentier E, Dhonneur G. Unanticipated difficult airway management in the prehospital emergency setting: prospective validation of an algorithm. Anesthesiology. 2011 Jan;114(1):105-10. doi: 10.1097/ALN.0b013e318201c42e. PMID: 21169803.

Author Response File: Author Response.docx

Reviewer 2 Report

This paper proposed a barrier systems to help protect health care providers during tracheal intubation. The authors claimed that the video intubating stylet shows promise to become the preferred intubation device in conjunction with plastic sheet barriers during the COVID-19 pandemic, however, there is not enough data or experimental statistics to support their statement.

1. What is the influence of the plastic sheet on the breathing of the patients? Does using plastic sheet endanger the normal breath of the patients?
2. Is intubating stylet first used in this study to perform endotracheal intubation?
3. This paper does not provide any data or experimental results to show the efficacy of the plastic sheet or intubating stylet in terms of preventing environmental contamination.
4. There are certain advantages of using intubating stylet, however, this paper does not provide enough evidence to show its efficacy. Is it possible to perform a statistical analysis regarding the efficacy of different barrier systems?

Author Response

Response to the Reviewer 2:

This paper proposed a barrier systems to help protect health care providers during tracheal intubation.

Q 1: The authors claimed that the video intubating stylet shows promise to become the preferred intubation device in conjunction with plastic sheet barriers during the COVID-19 pandemic, however, there is not enough data or experimental statistics to support their statement.

A 1: The authors appreciate the reviewer’s excellent and constructive comments on several issues to be addressed as follows.

The authors totally agree with the notion that, in this report, there are no enough “experimental” data for our statement regarding the promising role of video intubating stylet with plastic sheet barriers during COVID-19 pandemic.

Actually, this prediction is based on the authors’ own clinical experiences, practice, and observation in the latest 5 years. Since the COVID-19 outbreak and later pandemic, the authors started using plastic sheet as a barrier to protect the intubators from being contaminated. The unique clinical experiences of using video intubating stylet with plastic sheet barrier proved to be effective and valid. For example, the author adopted this method to uneventfully intubate three serious COVID-19 patients in the negatively pressurized isolation units, regarding the safety and effectiveness issues. During the sudden siege of COVID-19 in Taiwan since May, 2021, there were 16,000 new cases and 843 deaths during this short period of time. It is estimated there are 400 cases who need tracheal intubation and mechanical ventilator support during this period. Unfortunately, there are 3 incidents and more than 15 airway managers and team-members were accidentally contracted by the AGMP (all used video laryngoscopy for tracheal intubation). In addition, reportedly, there are incidents of multiple attempts of intubation, dental injuries, serious desaturation due to prolonged trial of intubation, etc. In contrast, our own experience showed the advantageous and outstanding results: swift, smooth, and safe intubation. No failed intubation or contraction of COVID-19.

Meanwhile, during the last 5 years, in our hospital which is a tertiary medical center in Taiwan, preference of using video intubating stylets is overwhelming and approaching to 90% of all the oral tracheal intubation cases (see Table 1 in the revised text). The rest of non-VISA users had different reasons not to use it, including unwilling to learn new technique, intend to promote use of disposable laryngoscopic blades, and for airway teaching purpose, etc.

Therefore, according to the authors’ own experience, we boldly anticipate the promising role of video intubating stylet and plastic sheet barrier in the field of airway management.

Q 2: What is the influence of the plastic sheet on the breathing of the patients? Does using plastic sheet endanger the normal breath of the patients?

A 2: Fortunately, the plastic sheet does not influence on the breathing of the patients at all. This is because one has to prepare the plastic sheet onto the video intubating stylet in advance. The patient is kept on routine pre-oxygenation (e.g., high flow nasal cannula). Only after the patient is totally under the adequate effects of sedatives (intravenous induction agents) and neuromuscular blocking agents, the airway manager starts the tracheal intubation procedure.

Therefore, using plastic sheet does not endanger the normal breath of the patients.

Q 3: Is intubating stylet first used in this study to perform endotracheal intubation?

A 3: As aforementioned, in Taiwan and at our institution, the video intubating stylet technique has been overwhelmingly adopted and popular. Therefore, this technique is not a new one for us. It has become a routine tracheal intubation technique. We added Table 1 to illustrate the high use coverage of such intubating technique.

Q 4: This paper does not provide any data or experimental results to show the efficacy of the plastic sheet or intubating stylet in terms of preventing environmental contamination.

A : Indeed, the assessment of “effectiveness and safety” of plastic sheet barrier with intubating stylet technique was not the main research focus in our article. That is to say, the purpose of the entry paper is to provide a perspective of such novel clinical idea. Other regulatory science issue about this practice awaits further studies. Again, the authors like to emphasize that the main purpose of our entry paper is to provide perspectives of such issues. And definitely one needs more experimental data to support the statement on the advantages of our intubating modality. Meanwhile, the authors also like to point out that so far there is no “valid” simulation models to test the effectiveness of any barrier against COVID-19 aerosols or airborne transmission. More important, there is no issues of cough and bucking during intubation process (in contrast, those might occur during extubation).

The authors has provided the preliminary data regarding the plastic sheet barrier on spreading of larger sized aerosols and particles (Figure ). The results implied the effects of plastic sheet barrier on spreading of saliva and secretion. Meanwhile, the authors had actual experiences on three COVID-19 patients in the negatively pressurized isolation units. However, the authors repeatedly emphasized the crucial role of PPE.

Q 5: There are certain advantages of using intubating stylet, however, this paper does not provide enough evidence to show its efficacy. Is it possible to perform a statistical analysis regarding the efficacy of different barrier systems?

A 5: As mentioned earlier, it was not the authors’ intention to test the “effectiveness & safety” of the plastic sheet barrier & intubating stylet technique in this article. Therefore, there are no prospective or retrospective clinical trials conducted based on this goal. Those issues need further clinical evaluation and that is exactly the purpose of this entry paper.

Author Response File: Author Response.docx

Reviewer 3 Report

In this article, Tsai and Luk described the development, during a pandemic emergency, of tools to protect healthcare professionals from risk of SARS-CoV-2 infection during their interventions on infected or potentially infected patients that need intubations. The article is divided in 6 paragraphs, describing protection (rigid boxes versus transparent plastic sheets) and intubation (general videolaryngoscopes versus video intubating stylet) tools. Everything is scientifically sounding, and although sometimes the flow is a bit hard to follow, the concepts are clearly stated. The reviewer has therefore only minor comments which would like the authors to address:

• Paragraph 5 contains an interesting literature analysis to corroborate the concept expressed. Although everything well described, the reviewer has the feeling that adding a table summarising the author's findings may ease the deliver of such analysis.
• Within the article it seems clear that the use of plastic sheets rather than rigid boxes is preferred as barrier system, especially if the holes for (video)laryngoscopes manipulation are minimal. What is less clear in the article is the process of disposal of such biohazard plastic sheets once used. A comment in this regard, also taking in account the cost and environmental impacts, may add some more deepness to the analysis.
• At the end of paragraph 2, at page 3, the list numbering is wrong, since the number 8 comes before the number 7. Please correct the mistake prior to the final form of the article.
• Similarly, the number of the conclusion paragraph should be 6, since the previous paragraph was already numbered as 5. Please correct accordingly.
• The reference layout does not match with the rest of the article. Could the authors double check that prior to the final version?

Author Response

Response to the Reviewer 3:

In this article, Tsai and Luk described the development, during a pandemic emergency, of tools to protect healthcare professionals from risk of SARS-CoV-2 infection during their interventions on infected or potentially infected patients that need intubations. The article is divided in 6 paragraphs, describing protection (rigid boxes versus transparent plastic sheets) and intubation (general videolaryngoscopes versus video intubating stylet) tools. Everything is scientifically sounding, and although sometimes the flow is a bit hard to follow, the concepts are clearly stated. The reviewer has therefore only minor comments which would like the authors to address:

Q 1: Paragraph 5 contains an interesting literature analysis to corroborate the concept expressed. Although everything well described, the reviewer has the feeling that adding a table summarising the author's findings may ease the deliver of such analysis.

A 1: The authors wish to thank the reviewer for the excellent comments and suggestions.

In response to the reviewer’s suggestion, the authors added the Table 2 to summarize the advantages and weakness of the two different barrier systems.

Q 2: Within the article it seems clear that the use of plastic sheets rather than rigid boxes is preferred as barrier system, especially if the holes for (video)laryngoscopes manipulation are minimal. What is less clear in the article is the process of disposal of such biohazard plastic sheets once used. A comment in this regard, also taking in account the cost and environmental impacts, may add some more deepness to the analysis.

A 2: The process of disposal of used plastic sheet has already been described in the last paragraph of the section 4 (also described in details in the Reference 40).

The stylet itself is regarded as a source of contamination from the patient’s airway secretion and saliva. Therefore, one needs to handle the stylet carefully and dis-infect according to the local health regulations (dis-infection policies and standard operating procedures). One sentence has been added in the revised text.

Q 3: At the end of paragraph 2, at page 3, the list numbering is wrong, since the number 8 comes before the number 7. Please correct the mistake prior to the final form of the article.

A 3: The typo-errors have been corrected in the revised text.

Q 4: Similarly, the number of the conclusion paragraph should be 6, since the previous paragraph was already numbered as 5. Please correct accordingly.

A 4: The typo-errors have been corrected in the revised text.

Q 5: The reference layout does not match with the rest of the article. Could the authors double check that prior to the final version?

A 5: The authors will check the layout of the manuscript before sending the revised draft of the manuscript. Appreciated!

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The reviewer reevaluated the manuscript entitled "Sheet Barrier and Intubating Stylet" by Tsai et al.  First, the reviewer respects the authors' perseverance and professionalism, time and effort spent on this revision. The manuscript seems to be improved in terms of its scientific value and readability through this revision. My remaining comments are all about minor points:

1

The left panel of Figure 1, Figure 3A

"Samsung Triple camera 2021” This capture description is unnecessary and should be deleted.

2

Page 4

3. Tracheal Intubation during the COVID-19 Pandemic

2nd para "The airway manager is able to obtain a view of the patient’s airway and guide the ETT through the patient’s glottis without placing <his> face in close proximity to the patient’s airway (Figure 4B)."

3

"His face" should be "his or her" face.

4

Keep abbreviations to a minimum. Please do not use abbreviations unless they appear at least three times in the text. The example includes LMA and GA.

5

Table 1, CRNA

This abbreviation is used without definition. Please spell out and delete CRNA.

6

Reference 63

Two papers, Cooney et al and Kok et al are mistakenly combined.

Author Response

Reviewer 1:

The reviewer reevaluated the manuscript entitled "Sheet Barrier and Intubating Stylet" by Tsai et al.  First, the reviewer respects the authors' perseverance and professionalism, time and effort spent on this revision. The manuscript seems to be improved in terms of its scientific value and readability through this revision.

My remaining comments are all about minor points:

Q 1: The left panel of Figure 1, Figure 3A "Samsung Triple camera 2021” This capture description is unnecessary and should be deleted.

A 1: The watermark of “Samsung Triple camera 2021” in both the Figure 1 and Figure 3 have been obscured and masked. Thank you!

Q 2: Page 4. Section 3. Tracheal Intubation during the COVID-19 Pandemic. 2nd para "The airway manager is able to obtain a view of the patient’s airway and guide the ETT through the patient’s glottis without placing <his> face in close proximity to the patient’s airway (Figure 4B)." "His face" should be "his or her" face.

A 2: “his face” has been corrected to “his or her face”. Thank you!

Q 3: Keep abbreviations to a minimum. Please do not use abbreviations unless they appear at least three times in the text. The example includes LMA and GA.

A 3: The abbreviations such as “LMA”, “GA”, “ET” in Table 1 have been deleted. Instead, “laryngeal mask airway”, “general anesthesia”, and “endotracheal tube” have been spelled out in the Table 1. Thank you!

Q 4: Table 1, CRNA. This abbreviation is used without definition. Please spell out and

delete CRNA.

A 4: “CRNA” has been replaced with “certified registered nurse anesthetists”. Thank you!

Q 5: Reference 63. Two papers, Cooney et al and Kok et al are mistakenly combined.

A 5: References 63 and 64 have been separated and sequenced accordingly. Thank you!

Please also see the attachement.

Author Response File: Author Response.pdf

Reviewer 2 Report

My previous comments and questions have been answered. The entry can be published in present form in my own opinion. 

Author Response

Reviewer 2:

My previous comments and questions have been answered. The

entry can be published in present form in my own opinion.

A: Thanks for your excellent and professional review and comments.

Please also see the attachment.

Author Response File: Author Response.pdf