Comparison of a novel low-cost hyperangulated video intubation stylet with the Bonfils fiberscope: a simulated difficult airway manikin study.

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Introduction Optic stylets are safe, efficient airway tools, with improved intubation success rates compared to direct laryngoscopy. Economic constraints often limit access to costly difficult airway equipment. The Hyperangulated Video Intubation Stylet (HiVIS) is a novel, low-cost, stainless-steel stylet with a Wi-Fi camera connecting to a smartphone. We aim to demonstrate that performance of the HiVIS, as an alternative low-cost device, is non-inferior to the Bonfils. Methods We performed a randomised, cross-over non-inferiority study following institutional and ethics approval (UCT HREC 816/2020). Randomised participants received training (instructional video and practice intubations on a Laerdel airway manikin™) and subsequently intubated a Trucorp Airsim manikin™ simulating a difficult airway with the Bonfils and HiVIS alternately. Our primary outcome was time-to-intubation with a pre-specified non-inferiority margin of 5 seconds. Secondary outcomes were best laryngeal view, airway trauma, and number of attempts. Participants completed a questionnaire regarding device preference and overall satisfaction. Results Thirty doctors participated: 33% interns and 54% medical officers from various specialties. 63% performed ≤1 intubation per week, and 10% had optical stylet experience. Both devices had 100% first-pass intubation success: 10.4 seconds Bonfils versus 11.2 seconds HiVIS (p<0.0001). The mean difference in time-to-intubation was 0.8 seconds (90% CI -0.4; 2.1). All Bonfils intubations had a grade 1 laryngeal view compared to 83% of HiVIS intubations (27% grade 2). The Bonfils had the only incident of airway trauma. Two-thirds of participants preferred HiVIS, with similar user satisfaction scores for both devices. Conclusion The HiVIS is non-inferior to Bonfils in a single attempt difficult airway manikin simulation with predominantly novice, non-anaesthesia users. The HiVIS could be a cost-effective tool for difficult airway management in resource-constrained settings.