Embracing the robotic revolution into anaesthetic practice

Abstract

‘It is not the strongest species that survive, nor the most intelligent, but the ones most responsive to change’ —Charles Darwin Three years after Christopher Columbus first set sail to the Americas, Leonardo da Vinci designed one of the first humanoid robots in 1495: a mechanical, armoured knight used for entertaining royalty 1. Whilst da Vinci's robot was far from the first example of automated devices (examples are reported from the 1100s 2), mainstream uptake has only recently occurred. Today, there are countless implementations of robotic technology in all guises of life, including the multiple facets of healthcare, but until now there has been little development in automation in the setting of airway management. In this issue of Anaesthesia, Biro et al. have published their proof-of-concept manikin study exploring whether the use of robotic endoscope automated via laryngeal imaging for tracheal intubation (REALITI) can facilitate tracheal intubation 3. This video-endoscope allows manual movement of the endoscopic tip using a joystick at the proximal end of the device, much like a traditional flexible bronchoscope. The device also utilises image-recognition software which can allow 360° circular automated movements of the tip towards the glottis when characteristic anatomical features are recognised. Once the automated mode has been activated, the tip moves in the direction of the geometrical centre point of the glottis. In this study, seven anaesthetists and seven lay persons performed six consecutive device insertions into the trachea of an airway manikin using the joystick, followed by six tracheal intubations using the automatic mode. The key findings were that the automated mode was associated with a faster time to access the trachea compared with the manual mode. Similarly, as users gained more experience with the device, they achieved this desired endpoint faster. The authors report that these findings support the aim of the REALITI project which is to increase successful tracheal intubations by anaesthetists and non-anaesthetists alike. This study suffers several limitations which many readers will easily spot. Firstly, as noted by the authors, tracheal intubation was not actually performed. This is the key endpoint that many studies use to assess the clinical efficacy of devices, both in manikin and patient studies 4, and perhaps should have been the primary metric reported in this study. Indeed, this somewhat undermines the final two words of the device's name. Secondly, the authors compared two arms, both using the REALITI device, but did not compare traditional methods for tracheal intubation with direct laryngoscopy, videolaryngoscopy or flexible bronchoscopy. This would be a logical next step, but its omission in this provisional phase of development is significant. And finally, the comparison of manual and automated modes only demonstrated a speed difference of 5.5 s, which has no real clinical relevance. However, the novelty of this study lies in the ability of the REALITI device to recognise glottic features and subsequently steer the endoscope tip into the trachea automatically. This is the first application of such technology in anaesthetic practice and despite clinical practice still being far off from robot-assisted or automated tracheal intubation, it is a step closer to that exciting vision. Whilst the REALITI system is the first that has been specifically designed to aid tracheal intubation, similar technology has been developed for diagnostic bronchoscopy and lung biopsies. The Ion™ endoluminal system (Intuitive Surgical, Sunnyvale, CA, USA) is a robot-assisted platform for performing minimally invasive lung biopsy procedures. The robotic components allow advanced manoeuvrability and navigation of a catheter into the lung periphery using fibreoptic shape-sensing technology to precisely position and stabilise the catheter for accurate lung biopsies. It also contains software which generates a three