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Reply to: Taipei Azalea: Another example of “MacGyver bias” during COVID-19 pandemic?

      To the Editor,
      We thank Leong et al. for evaluating our design and listing several concerns which we had also discussed and worth sharing here.

      Leong YC, Cheskes S, Latchmansingh RG, et al. Taipei Azalea: Another example of “MacGyver bias” during COVID-19 pandemic? Not yet published.

      First of all, we put many efforts to make sure the development of Taipei Azalea being an ethically sound and medically informed process. The materials we used are commercially available, but the way we use them has not been verified before. It was designed as a contingency care for patients suffered from very real biological threats.

      Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, Institute of Medicine. 2012 March 21.

      The whole combination may not be 100% effective, but it is also hard to believe it will totally fail either.
      We had two principles to guide the development for prehospital airway management protocol. The first is simple. It is quite difficult for 2-man crew to attach the filter to the SGA device on scene while simultaneously providing resuscitation. By pre-packaging airway kit before arrival, we made the “new way” as familiar as what EMTs has been trained for years to ease cognitive loads.
      Second, to better serve our patients, we have to keep it fast. Our goal is not to create a complete seal, but to help patients and staying safe at the same time. Chest compression fraction (CCF) suffers when we desperate to seal every leak. With adequate PPE, our EMTs did not solely depend on Taipei Azalea. Recently, Scapigliati A, et al. introduces another concept also using i-gel® during resuscitation.
      • Scapigliati A.
      • Gullì A.
      • Semeraro F.
      • et al.
      How to ventilate during CPR in time of Covid-19?.
      By placing two adhesive drapes, it might provide better protection than Taipei Azalea; however, similar to aerosol boxes, these designs could slow down resuscitation efforts. Difficult Airway Society advocates SAS principle (Safe, Accurate, Swift) for COVID-19 airway management, and we are delighted to know that under the circumstance of reasonably enough PPE protection, our principle of simple & fast is quite similar to theirs.
      • Cook T.M.
      • El-Boghdadly K.
      • McGuire B.
      • McNarry A.F.
      • 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.
      The pre-packaging did render the i-gel® non-sterile and the kit may be damaged by external compression, but that is the trade-off for simple & fast deployment. For concerns regarding HMEF, the device captures virus by both mechanical and electrostatic mechanisms and we did not foresee any reason that could lead to device failure simply by the removal from original package. We respect vendor’s declaration but take it as a legal statement rather than a proof of ineffectiveness. Although paramedics in Taipei are capable of tracheal intubation, the CPR pause could last too long if first attempt failed. Therefore, we suggest paramedics in Taiwan also use Taipei Azalea as the primary airway during the epidemic.
      In conclusion, the development of Taipei Azalea may be associated to quick-witted MacGyver who can improvise in just few seconds, but in reality, it was deliberated for days. As of 27th June, Taiwan has 447 COVID-19 cases, with 91 cases managed by Taipei EMS, and none of them suffered from out-of-hospital cardiac arrest, hence it is too early to say anything about Taipei Azalea. For other international EMS using exact or similar method, we suggest carefully monitor the infection rate of crew members.

      Author declaration of interests

      The authors declare no conflicts of interest.

      References

      1. Leong YC, Cheskes S, Latchmansingh RG, et al. Taipei Azalea: Another example of “MacGyver bias” during COVID-19 pandemic? Not yet published.

      2. Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, Institute of Medicine. 2012 March 21.

        • Scapigliati A.
        • Gullì A.
        • Semeraro F.
        • et al.
        How to ventilate during CPR in time of Covid-19?.
        Resuscitation. 2020; 151: 148-149
        • Cook T.M.
        • El-Boghdadly K.
        • McGuire B.
        • McNarry A.F.
        • 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; 75: 785-799