From bending to standing upright: augmented reality technology: a new trend in laryngoscopy?

Tracheal intubation is performed frequently by medical professionals in the fields of anaesthesia, intensive care and emergency medicine. However, existing laryngoscopes are neither ideal nor ergonomically designed [1]; intubating the trachea with a direct laryngoscope, such as Macintosh and Miller laryngoscopes, requires the operator to bend the waist to nearly 40° and position their face near the patient's mouth (Fig. 1a). This awkward posture and the patient's breath have been reported as physical and mental stressors for the operators during tracheal intubation [2]. This may result in repetitive strain injury with pain; tingling; numbness; stiffness; muscle cramps; and anxiety. While using a videolaryngoscope enables a more ergonomic posture [3], it does not entirely resolve the issue. For example, the GlideScope® videolaryngoscope (Verathon, Bothell, WA, USA) has a separate screen from the device itself, causing operators to experience discomfort when turning their heads to view the screen [4]. Some operators prefer laryngoscopes with integrated screens due to their lightweight design and convenience; however, the integration of the laryngoscope and its video screen results in operators bending down and lowering their head to view the screen (Fig. 1b). Augmented reality technology holds great potential for enhancing clinical procedures such as central venous line placement, cardiopulmonary resuscitation and extracorporeal membrane oxygenation device management [5]. To address the challenges associated with existing laryngoscopes, we present a pioneering augmented reality laryngoscope. This laryngoscope features integrated augmented reality glasses and a wireless Wi-Fi component, enabling the operator to view the image in front without the need to bend down (Fig. 1c). The setup process for the augmented reality laryngoscope and the tracheal intubation procedure are shown in online Supporting Information Video S1. The augmented reality laryngoscope was constructed using Epson® Moverio BT-300 AR glasses (Seiko Epson Corporation, Owa, Suwa-shi, Nagano, Japan), which includes a 0.43-inch silicon Si OLED display panel. Operating on the Android 5.1 system, these glasses can project an approximately 80-inch, 720p image and supports both Wi-Fi and Bluetooth connectivity. In addition, a Depstech Wi-Fi industrial endoscope WF028-f (GuangDong, China), featuring a 5-megapixel lens, has been integrated. The endoscope is equipped with six high-quality LED lights, and the Wi-Fi hotspot for connection is provided by the WF028. Since the endoscope is not custom-made, a 3D-printing method was employed to produce the laryngoscope and handle with a compatible sleeve (online Supporting Information Video S1). The printing material, typically derived from tree esters, has successfully passed strength tests. We initially tested this system with a tracheal intubation model and achieved satisfactory results, particularly regarding operator satisfaction, postural comfort and image clarity (Table 1). The operator observed an 80-inch larynx image display (see online Supporting Information Figure S1). Figure 1 illustrates the angles formed between the operator's waist and the vertical line for three different laryngoscopes. With the augmented reality system, operators can move more freely without being constrained by the screen position or needing to lean close to the patient's mouth. This system represents our first attempt in developing a conceptual product, identifying several areas that require improvement. Our primary objective is to create a portable, fully developed head-mounted display system for augmented reality laryngoscopy. Such a system would enhance the experience of both clinical operators and students alike, offering dedicated equipment for clear image visualisation and reducing eye strain caused by small screens. This research was supported in part by the Science and Technology Support Project of Xinjiang Uyghur Autonomous Region (No. 2022E02059) and the Basic and Applied Basic Research Joint Funding Project of Huadu District (No. 23HDQYLH05). We would like to thank Dr Y. Zhou for helping with the video recording and editing. No competing interests declared. Figure S1. The operator's field of view through the augmented reality glasses when performing a tracheal intubation. Video S1. Different 3D-printed laryngoscopes, matching sleeves and recordings of the augmented reality laryngoscope preparation and tracheal intubation procedure. Video recorded by ZD in the operating theatre of the Huadu District People's Hospital in October 2023 and edited by NS in November 2023. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.