Author s response to reviews

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1 Author s response to reviews Title: Comparison of VividTrac, Airtraq, King Vision, Macintosh Laryngoscope and a Custom-Made Videolaryngoscope for Difficult and Normal Airways in Mannequins by Novices Authors: Szilárd Rendeki (rendekiszilard@gmail.com) Dóra Keresztes (keresztesdora87@gmail.com) Gábor Woth (glwoth@gmail.com) Ákos Mérei (merei.akos@gmail.com) Martin Rozanovic (rozanovic.martin@gmail.com) Mátyás Rendeki (rendekimatyi@gmail.com) József Farkas (jozsef.farkas@aok.pte.hu) Diána Mühl (drdianamuhl@gmail.com) Balint Nagy (balintjanosnagy@yahoo.com) Version: 2 Date: 14 Apr 2017 Author s response to reviews: Matthew John Meyer, M.D. Editor BMC Anesthesiology April 14th, 2017 Comparison of VividTrac, Airtraq, King Vision, Macintosh Laryngoscope and a Custom- Made Videolaryngoscope for Difficult and Normal Airways in Manikins by Novices Dear Matthew John Meyer, M.D., First of all, thank you for re-evaluating our manuscript! Based on the received valuable editorial recommendations and comments, we made significant efforts to revise our manuscript. All the corrections are marked as recommended by BMC Anesthesiology, however probably due to technical problem we could not upload the track

2 changes version of our revised manuscript without obstructing boxes in the final pdf version. Eventually we decided to upload the plain text (after acceptance of all the changes) for building up the pdf, while track changes manuscript version is included as a supplementary material. Sorry for the inconvenience and thank you for the understanding! Please find our detailed, point by point response below! We also include below the authors reply to the reviewers! Editor Comments: Thank you for your revision. The manuscript reads a little better but is still informally written, confusing to follow, long, and it contains many errors in English syntax and grammar. Please revise accordingly and use more concise, scientific language and fewer parenthetical clauses. Please find below a list of specific comments--please address each comment individually. Along with these comments please improve the flow and organization of the complete manuscript. Prior to resubmission, It may be helpful to have someone unfamiliar with your study read through the manuscript and identify difficult to understand sections that require further revision. With the help of the Premium Editing Service of American Journal Experts, we corrected our manuscript regarding all the aforementioned English language errors. Please find the Certificate of American Journal Experts regarding our manuscript as a supplement of this resubmission. Introduction--simplify the introduction, please present only the premise for the study and acknowledge that your reader will be knowledgeable in the basics of airway management tools *Despite the proven benefit of VL over DL in difficult airways, the clinical availability of VL remains gloomy, especially in low- and middle-income countries [9 11]. Whether or not VL is better than DL in difficult airways is up-for-debate and should be presented as such. There may be advantages in certain challenging situations to VL but this may be true of DL as well. Thank you for this recommendation! We simplified the Introduction/Background and added the following sentence regarding the role of VL in airway management: Videolaryngoscopy (VL) might be beneficial compared to DL for novices, although the role of VL in airway management remains controversial [3-4]. The disapproved sentence is replaced by Although patients may benefit from the availability of VL, especially in difficult airway situations, the clinical availability of VL remains limited, especially in low- and middle-income countries [5 7]. Methods

3 *The methods section is five pages long for a relatively simple study: 50 novices, 5 devices, 2 scenarios, and a handful of outcomes. I disagree that the reader needs this much text to understand the study. I am concerned the length of the methods may turn-off the reader from finishing the manuscript. Please shorten the methods section by using more precise language and removing superfluous explanations. Thank you for the detailed reasoning regarding the recommended length of Methods section! We agree that a lengthy manuscript might turn-off the reader from finishing the paper, thus we made every efforts to shorten and simplify the Methods along with editorial recommendations. The current version has 3 pages long Methods (statistical section included), which we hope sufficiently short for the readers, but still contains all the essential information regarding the methodology of our study. *Please use sub-headings in the methods to assist with organization. The methods section is currently difficult to follow linearly. Thank you! The Methods section is currently divided into the following subsections to assist following of the text: Ethics and sample size calculation ; Devices ; Training ; Evaluation ; Statistical analysis *However, we managed to recruit 50 voluntary medical students, all without prior experience in DL or VL This is a result in the methods section. Thank you! Moved to the Results and omitted from the Methods! *We chose the POGO score over Cormack and Lehane grade to express laryngeal view, due to the intra- and inter-rater reliability, is largely proved to be better more reliable by the POGO score system [17]. This sounds like something that could be discussed rather than included in the methods. Or if you think it belongs in the methods it should be attached as a few word clause and citation to the sentence immediately before it. Thank you! Moved to the Discussion and omitted from the Methods! *VividVision and Airtraq Mobile softwares were was used for VT, ID and AT, respectively. There are two softwares and three devices--this does not make sense, one software is missing or one device should be removed. Thank you! Actually VividVision as a software is ready to handle ID as well, therefore VividVision was used for VT and ID, while Airtraq Mobile software was used for AT. However, we approve that the aforementioned sentence might be misleading, thus ID was removed from the sentence.

4 Current version: VividVision and Airtraq Mobile software was used for the VT and AT, respectively. Results *The results should be limited to results--not interpretation of the results. Frequently, this results section generalizes and comments upon results rather than presenting the numbers and statistics in a simple fashion. Please eliminate discussion from the results. Thank you! We made corrections on Results along your recommendations and we hope that you will find the current version acceptable. *The custom-made device (ID) was significantly slower in this regard. I do not know to what outcome this sentence is referring. Thank you! The sentence might be confusing, thus we omitted! * The performance of ID was even far worse in IT than DL What device is IT? IT stands for Intubation Time as explained in the Methods, however we corrected the sentence. *Interestingly, we experienced more an increase in dental injuries by in the use of the VL s when compared to the DL. This sort of commentary belongs in the discussion not the results. Thank you! The sentence is removed from the Results. Discussion *The discussion is challenging to follow. It has many run-on sentences with incorrect english syntax for example: However, in the MILS scenario, we noted a similar (KV, VT) or even higher (ID, AT) rate of dental injury by VL s when compared to the DL, which might may likely be due to limited operator experience or the degree of difficulty in the effective device insertion, in during the lack of the neck reclination to fully recline, especially by the use of the VAT (a bulky head part due to the phone adapter). Thank you! Editors of American Journal Experts hopefully corrected all the critical points regarding English syntax and manuscript flow.

5 *Annual worldwide incidence of failed intubation related fatalities is estimated to be 600 [21]. This estimate comes from a 1990 manuscript that refers to the 1988 manuscript Criteria for estimating likelihood of difficulty of endotracheal intubation with the Macintosh laryngoscope. It also states, in the 1990 paper, that the estimate is in the developed world. I do not believe this estimation is currently valid. Thank you! Sentence and the related reference are omitted. Conclusion *The entire study assessed novices--therefore all concluding statements must be qualified in novices. Thank you! Recommendation approved! The following sentences of the Conclusion refers to novices: In conclusion, performance with the custom-made ID in novices was at best similar, but mostly inferior, to a regular DL. Based on our results, the tested commercially available VLs can be recommended in both scenarios over the DL for students or specialists in training. Table 2 *The superscripts to identify the differences between the means for VT are obscured on some rows by the track changes boxes saying formatted. These should not be present on a revision submission. Thank you! Sorry about the technical problem! Thank you for reconsidering our paper! We hope that after this revision, you will find our manuscript suitable for publication in BMC Anesthesiology! Dear Masood Mohseni (Reviewer 1), Thank you for your time and for the professional review! We completely agree with your comment, that some of our results are not novel. However, to our knowledge this is the first study included VividTrac. Custom-Made Videolaryngoscope has already been evaluated before, but only small and poorly controlled trials are available in the literature. Therefore, according to our opinion the comparison of the aforementioned devices to already tested scopes might be interesting for wide scope of medical readership. Furthermore, choosing between scopes in the clinical practice by non-professionals is presumably strongly based on their

6 minimal previous experience, thus the also reported user satisfaction might be interesting as well. Your recommendations regarding CMAC and Glidescope are really interesting and we will utilize the related suggestions in our future studies. We aimed to shorten and summarize the manuscript as recommended and we managed to decrease the overall length significantly. We hope that you will accept our answers and find the revised manuscript sufficient for publication. Dear White Rodger (Reviewer 2), Thank you for your time and for the expert review! Based on our experience we completely agree with your comment, that non-channelled VL s might be better for professionals, while for novices the scopes with channelled blade are more useful. We also agree with the highlighted importance of the blade shape. We aimed to compare new and affordable scopes (ID, VT) to already tested popular ones (DL, KV, AT). It would be worthwhile in the future to include CMAC and Glidescope as structurally more similar scopes to explore differences between ID and similarly bladed scopes more in details. Thank you for recommending acceptance of our manuscript! Yours sincerely, Bálint Nagy, M.D. Department of Anaesthesiology and Intensive Therapy University of Pécs, Hungary HU-7624 Pécs, Ifjúság str. 13, Hungary Tel: , Fax: balintjanosnagy@yahoo.com