TECHNICAL COMMUNICATION The Kepler Intubation System Thomas M. Hemmerling, MSc, MD, DEAA, Mohamad Wehbe, MASc, Cedrick Zaouter, MD, Riccardo Taddei, MD, and Joshua Morse Our goal in this study was to develop a robotic intubation system and to conduct a feasibility pilot study on the use of a robotic intubation system for endotracheal intubations. The Kepler Intubation System was developed, consisting of a remote control center (joystick and intubation cockpit) linked to a standard videolaryngoscope via a robotic arm. Ninety intubations were performed by the Kepler Intubation System on an airway trainer mannequin by a single operator. The first group of 30 intubations was performed with the operator in direct view of the mannequin (direct view group). The second group of 30 intubations was performed with the operator unable to see the mannequin (indirect view group). Thirty semiautomated intubations were also performed during which the robotic system replayed a trace of a previously recorded intubation maneuver (semiautomated group). First-attempt success rates and intubation times for each trial were recorded. Trends were analyzed using linear regression. Data are presented as mean (SD). All intubations were successful at first attempt. The mean intubation times were 46 (18) seconds, 51 (19) seconds, and 41 (1) seconds for the direct view, indirect view, and semiautomated group, respectively. Both the direct and indirect view groups had a negative slope, denoting that each successive trial required less time. The semiautomated group had a slope of 0 and a low SD of 1 second, illustrating the high reproducibility of automated intubations. We concluded that a robotic intubation system has been developed that can allow remote intubations within 40 to 60 seconds. (Anesth Analg 2012;X:•••–•••) E ndotracheal intubation is a complex procedure of inserting an endotracheal tube (ETT) into the trachea of an anesthetized patient to allow artificial ventila- tion. Endotracheal intubations, commonly performed with high success rates in anesthesia departments, can be asso- ciated with lower success rates in emergency departments, where intubation success rates can be as low as 70% at first attempt and 89% at second attempt. 1 The prehospital success rates of endotracheal intubations have been re- ported to be as low as 49.1%, 2 performed by rural basic emergency medical technicians. A study conducted by Tighe et al. demonstrated the possibility of using a multipurpose surgical robot to assist in airway management 3 ; however, the expense of such a system prohibits its widespread adoption for this applica- tion. In addition, urologists used the da Vinci surgical system for either oro- or nasopharyngeal fiberoptic intuba- tion, which is not the standard practice in anesthesia. However, recently widespread use of videolaryngoscopic devices has increased, and they have been introduced into guidelines of difficult airway, with some anesthesiologists advocating their standard use in everyday practice. 4 This article presents the development and feasibility pilot study of the Kepler Intubation System (KIS), a robotic system developed using low-cost, commercially available components for performing endotracheal intuba- tions. This system is named in honor of the German mathematician and astronomer Johannes Kepler, best known for his laws of planetary motion. METHODS A remote-controlled robotic system was developed to in- tubate using a standard videolaryngoscope. This system is composed of 4 main components: a ThrustMaster T.Flight Hotas X joystick (Guillemot Inc., New York, NY), a JACO robotic arm (Kinova Rehab, Montreal, Quebec, Canada), a Pentax AWS videolaryngoscope (Ambu A/S, Ballerup, Denmark), and a software control system. Both the Pentax AWS videolaryngoscope and the JACO robotic arm are medical devices currently available on the market. The software control system was developed in C sharp (Mi- crosoft Corporation, Redmond, WA), and the graphical user interface was developed in LabVIEW (National Instru- ments, Austin, TX). The setup also included a commercial Webcam (Microsoft Corporation, Redmond, WA) placed laterally to the mannequin, providing a video feed of the videolaryngoscope going into the mannequin’s mouth (Fig. 1, right panel). The software control system of the KIS comprises a client and a server to allow intubations to be performed remotely from the operating room. The client and server communicate with each other via the Internet. The main interface of this system is the KIS Intubation Cockpit (shown in Fig. 1). Ninety endotracheal intubations were performed using an airway trainer mannequin (Laerdal Airway Manage- ment Trainer, Laerdal Medical, Stavanger, Norway) by the same anesthesiologist (T.H.) via a robotically mounted standard videolaryngoscope to determine first- attempt success rate and the average intubation time. The intuba- tion time was defined as the start of moving the KIS from From the Department of Anaesthesiology, McGill University, Montreal, Quebec, Canada. Accepted for publication November 4, 2011. Funding: Departmental funding. Conflict of Interest: See Disclosures at the end of the article. Reprints will not be available from the authors. Address correspondence to Professor Thomas M. Hemmerling, MD, DEAA, Department of Anaesthesiology, McGill University, Montreal General Hos- pital, 1650 Cedar Avenue Montreal, H3G 1A4, Quebec, Canada. Address e-mail to thomas.hemmerling@mcgill.ca. Copyright © 2012 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e3182410cbf XXX 2012 • Volume X • Number X www.anesthesia-analgesia.org 1