British Journal of Anaesthesia, 119 (5): 993–9 (2017)

doi: 10.1093/bja/aex272
Advance Access Publication Date: 14 September 2017
Respiration and the Airway

Comparison of the paediatric blade of the Pentax-AWS

and Ovassapian airway in fibreoptic tracheal
intubation in patients with limited mouth opening and
cervical spine immobilization by a semi-rigid neck
collar: a randomized controlled trial
D. H. Kim, J. Y. Yoo, S. Y. Ha and Y. J. Chae*
Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea

*Corresponding author. E-mail: yjchae06@hotmail.com

Abstract
Background. We compared the performances of the paediatric blade of a Pentax Airway Scope and an Ovassapian airway in
fibreoptic tracheal intubation in patients whose necks were stabilized by semi-rigid neck collars.
Methods. Ninety patients were enrolled in this prospective, open-label, randomized controlled trial. Patients were randomly
allocated to one of two groups (Group OVA-FOB and Group AWS-FOB). The time to tracheal intubation, success rate of tra-
cheal intubation, number of optimization manoeuvres (jaw thrust), and difficulty of manipulation of the fibreoptic broncho-
scope were compared between the groups.
Results. The time to tracheal intubation was significantly shorter (32 vs 50 s; median difference 19 s; 95% confidence interval
14–25 s; P<0.001) and manipulation of the fibreoptic bronchoscope was significantly easier for Group AWS-FOB.
Optimization manoeuvres were rarely required to facilitate fibreoptic tracheal intubation in Group AWS-FOB [jaw thrust, 0
(0%); jaw thrust with anterior neck collar removal, 1 (2%)] compared with that required in Group OVA-FOB [jaw thrust, 39
(87%); jaw thrust with anterior neck collar removal, 2 (4%)]. There was no significant difference in the success rate of tracheal
intubation on the first attempt between groups [Group AWS-FOB, 45 (100%); Group OVA-FOB, 44 (98%)].
Conclusions. Combined use of the paediatric blade of a Pentax Airway Scope and a fibreoptic bronchoscope enabled rapid
tracheal intubation, minimizing the use of external manoeuvres of the airway, in patients with limited mouth opening and
cervical spine immobilization by semi-rigid neck collars, compared with use of the Ovassapian airway and the fibreoptic
bronchoscope.
Clinical trial registration. NCT02827110.

Key words: airway management; bronchoscopes; laryngoscopes

Editorial decision: July 19, 2017; Accepted: July 25, 2017

C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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993
 994 | Kim et al.
Editor’s key points
• Fibreoptic tracheal intubation may frequently be diffi-
cult in patients with restricted neck movement, and the
use of an insertion aid may facilitate intubation.
• Comparison in the ease of fibreoptic tracheal intubation
was made between the use of an Ovassapian oral air-
way and a Pentax Airway Scope (with a blade of paedi-
atric size) as an insertion aid.
• The Pentax Airway Scope (with a blade of paediatric
size) was more useful than the Ovassapian oral airway
in facilitating fibreoptic tracheal intubation in patients
with restricted neck movement.
The presence of a neck collar has been associated with de-
creased mouth opening1 2 and worsening of direct laryngoscopic
view, consequently reducing the success rate of tracheal intuba-
tion.3 In such situations, fibreoptic tracheal intubation is a reli-
able method to obtain a high success rate of tracheal intubation
and minimize cervical spine movement.4 Under general anaes-
thesia, the loss of pharyngeal muscle tone reduces the oropha-
ryngeal space for passage of the fibrescope and makes it
difficult to maintain the fibrescope in the midline while advanc-
ing its tip into the pharynx and the laryngeal inlet.5–7 Moreover,
fibreoptic tracheal intubation becomes difficult when the head
and neck are stabilized.8 The Ovassapian airway is one of the
specific airways designed for making the oropharyngeal space
open and introducing the fibrescope in the midline of the oro-
pharynx.9 Despite the use of this airway, partial or total obstruc-
tion of the fibreoptic view is frequent,10 and the active
application of a jaw thrust manoeuvre is required in patients
with neck stabilization.9
Recently, there have been several reports on the combined
use of a fibrescope and a video laryngoscope.5 11–17 Among the
various types of video laryngoscopes, the channel of the Pentax
Airway Scope (Pentax-AWS; Pentax Corporation, Tokyo, Japan)
can be used for the passage of a fibrescope into the glottic inlet.
However, as the channel was originally designed for a tracheal
tube, an adult-sized blade is bulky for insertion; there is poor
manoeuvrability (multiple attempts) and a reported failure rate
of 17–30% with limited mouth opening.18–23 As a paediatric-
sized blade is thinner, it would be easier to insert into the
mouth and have better manoeuvrability in a narrow oropharyn-
geal space than the adult-sized blade. Moreover, when com-
bined with the use of a fibrescope, the optimal position might
be non-essential, thereby reducing the attempts for positioning.
We hypothesized that, in patients with semi-rigid foam neck
collars under general anaesthesia, the combined use of the pae-
diatric blade of the Pentax-AWS and a fibreoptic bronchoscope
would allow quicker tracheal intubation and require fewer ex-
ternal manoeuvres of the airway to facilitate intubation com-
pared with the use of an Ovassapian airway and the fibreoptic
bronchoscope.
Methods
This study was a single-centre, prospective, open-label, ran-
domized controlled superiority trial with two parallel groups.
The study protocol was approved by the Institutional Review
Board of Ajou University Hospital (Suwon, South Korea) and was
registered with ClinicalTrials.gov (NCT02827110). We recruited
patients from Ajou University Hospital in Suwon, South Korea
from June 2016 to December 2016. Patients with ASA physical
status class I or II, aged 20–65 yr, and undergoing robot-assisted
or laparoscopic cholecystectomy were eligible for inclusion.
Patients with histories of cardiopulmonary, gastrointestinal, or
upper airway disease, increased risk of pulmonary aspiration,
BMI>30 kg m2, or poor dentition were excluded. Written in-
formed consent was obtained on the day before surgery. Before
induction of anaesthesia, the patients were randomly assigned
in a 1:1 allocation ratio to one of two groups (Group OVA-FOB
and Group AWS-FOB) by computer-generated codes that were
maintained in sequentially numbered, sealed, opaque
envelopes.
All patients received standardized general anaesthesia, in-
cluding electrocardiography, non-invasive monitoring of blood
pressure, pulse oximetry, capnography, and measurement of
volatile anaesthetic concentrations. After preoxygenation with
a tight-fitting mask for 3 min, anaesthesia was induced with
fentanyl (2 mg kg1) and thiopental sodium (4 mg kg1). After loss
of consciousness, manual ventilation by mask was undertaken
with sevoflurane (end-tidal concentration, 2–3%) in oxygen, and
rocuronium (0.6 mg kg1) was injected. Ninety seconds after
rocuronium injection, neck circumferences, mouth opening (in-
ter-incisor distance), and modified Cormack–Lehane grade by
direct laryngoscope24 were measured. After the appropriate size
of the semi-rigid foam neck collar (Philadelphia cervical collar)
was positioned around the neck according to the manufac-
turer’s recommendations, the measurements of the mouth
opening and modified Cormack–Lehane grade were repeated.
Tracheal intubation was then performed using one of the study
R
devices with a standard bevelled PortexV tracheal tube (Smiths
Medical, Hythe, UK; males, 8.0 mm internal diameter, 10.9 mm
outer diameter; females, 7.0 mm internal diameter, 9.6 mm
outer diameter). A flexible fibreoptic bronchoscope (PortaViewV
R
LF-GP; Olympus Optical Company, Tokyo, Japan) with an outer
diameter of 4.1 mm was used. The paediatric blade of the
Pentax-AWS was used. The acceptable outer diameter of the
tracheal tube was 5.5–7.6 mm without a cuff.
In all Group OVA-FOB participants, the Ovassapian airway
was inserted before insertion of the flexible fibreoptic broncho-
scope. In Group AWS-FOB, an anaesthetist inserted the paediat-
ric blade of the Pentax-AWS into the patient’s pharynx to obtain
a laryngeal view on the video screen and held it in place. If ele-
vation of the epiglottis was easily obtained in a single advance-
ment attempt, it was maintained while introducing the
fibreoptic bronchoscope. If the epiglottis could not be elevated
in one attempt because the paediatric blade was too short, we
did not attempt to elevate the epiglottis and instead introduced
the fibreoptic bronchoscope through a tube channel of the pae-
diatric blade of the Pentax-AWS. In these instances, we main-
tained the position of the paediatric blade without applying a
ventral (lifting) force to prevent impediment of the broncho-
scope resulting from contact between the tip of the fibreoptic
bronchoscope passing through the tube channel of the paediat-
ric blade of the Pentax-AWS and the posterior portion of the
tongue.
In both groups, if the fibreoptic view during advancement
was insufficient (i.e. not clear) or the advancement of the
fibreoptic bronchoscope into the laryngeal inlet was difficult to
perform, jaw thrust was requested. If difficulty in the advance-
ment of the fibreoptic bronchoscope into the laryngeal inlet was
encountered even after jaw thrust, we removed the anterior
portion of the neck collar and performed jaw thrust at once.
When the tip of the fibreoptic bronchoscope was positioned

above the carina, the Ovassapian airway was kept in place,
which was our routine method, and the paediatric blade of the
Pentax-AWS was carefully removed from the mouth to facilitate
isolation from the fibreoptic bronchoscope in the channel. The
preloaded tracheal tube was then railroaded over the fibreoptic
bronchoscope. If advancement of the tracheal tube was im-
peded during the attempt, the tracheal tube was withdrawn
over the fibreoptic bronchoscope and rotated 90 anticlockwise,
then re-advanced towards the trachea. After tracheal intubation
was accomplished, anaesthesia was maintained with sevoflur-
ane (end-tidal concentration, 1.5–2.5%) in 50% oxygen in an oxy-
gen–air mixture. Appropriate blood pressure and heart rate
were also maintained.
The time to intubation was defined as the time elapsed from
the opening of the mouth for insertion of the Ovassapian airway
or the paediatric blade of the Pentax-AWS to the removal of the
fibreoptic bronchoscope from the mouth after confirming the
placement of the tracheal tube in the trachea. Tracheal intuba-
tion was considered a failure if it was not completed within
120 s. If tracheal intubation failed, the method of the next tra-
cheal intubation attempt was left to the discretion of the anaes-
thetist in charge. Mucosal damage was defined as the presence
of a bloodstain in the Ovassapian airway or on the paediatric
blade of the Pentax-AWS after tracheal intubation. After these
steps, the neck collar was removed. All fibreoptic intubations
were performed by a single anaesthetist (D.H.K.), who was fa-
miliar with and had been trained in intubation using a fibreoptic
bronchoscope. He determined the difficulty of the fibreoptic
bronchoscope manipulation on a numerical rating scale (0–10).
Manipulation of the Pentax-AWS was done by another anaes-
thetist (Y.J.C.), who was familiar with the Pentax-AWS.
The primary outcome of this study was the time to tracheal
intubation. A power analysis suggested that a minimum of 41
patients in each group was required to demonstrate a difference
in the time to tracheal intubation of 15 s with an SD of 24 s from a
previous study25 to achieve 80% power at a 0.05 level of signifi-
cance. Considering a 10% dropout rate, the estimated total sam-
ple size was 90.
Statistical analysis was performed using SPSS version 21
(SPSS Inc., Chicago, IL, USA). All analyses followed the
intention-to-treat principle. Continuous data were tested for
normality of distribution using the Kolmogorov–Smirnov test.
Data were presented as means with SD when normally distrib-
uted and when Student’s t-test was used; non-normally distrib-
uted data were compared between groups using Mann–Whitney
U-tests and presented as medians with interquartile ranges.
Categorical data were presented as numbers and percentages.
The v2 or Fisher’s exact tests were used to compare the categori-
cal variables between the groups. P-values <0.05 were consid-
ered statistically significant. The difference between groups for
the primary outcome measure is reported with the 95% confi-
dence interval.
Results
Ninety-nine patients were screened for the study. Seven pa-
tients declined to participate. Two patients were excluded be-
cause of poor dentition. The participant flow diagram for the
study is presented in Figure 1. A total of 90 patients were en-
rolled, and all patients completed the study. There were no
missing data in the analysis. The patient characteristics and air-
way assessment data before and after the application of a semi-
rigid neck collar are shown in Table 1. Mouth opening was
Paediatric Pentax-AWS and fibreoptic intubation | 995
significantly reduced and modified Cormack–Lehane grade
worsened significantly after the semi-rigid neck collar was ap-
plied. There were no significant differences in patient character-
istics between the groups. In Group AWS-FOB, the epiglottis was
elevated in 14 out of 45 patients.
The time to tracheal intubation was significantly longer in
Group OVA-FOB patients than in Group AWS-FOB patients (me-
dian time, 50 vs 32 s; median difference, 19 s; 95% confidence in-
terval, 14–25 s, respectively; P<0.001). In terms of the success
rate of intubation, there was no significant difference between
the groups [44 (98%) vs 45 (100%)]. One patient in Group OVA-
FOB was considered as a failed tracheal intubation because it
took 134 s to achieve tracheal intubation. A greater number of
optimization manoeuvres were required to facilitate fibreoptic
tracheal intubation in Group OVA-FOB [jaw thrust, 39 (87%); jaw
thrust with anterior neck collar removal, 2 (4%)] compared with
the number required in Group AWS-FOB [jaw thrust, 0 (0%), jaw
thrust with anterior neck collar removal, 1 (2%)]. The numerical
rating scale for the difficulty in manipulating the fibreoptic
bronchoscope for tracheal intubation was significantly higher in
Group OVA-FOB compared with Group AWS-FOB (5 vs 4;
P¼0.005). There were no differences in the incidence of mucosal
damage between the two groups.
Discussion
The combined use of the paediatric blade of the Pentax-AWS
and a fibreoptic bronchoscope rendered tracheal intubation
quicker, with minimal use of external manoeuvres (jaw thrust)
of the airway compared with the use of the Ovassapian airway
and the fibreoptic bronchoscope in individuals wearing semi-
rigid neck collars under general anaesthesia.
In patients with a neck collar, the mouth opening was con-
siderably reduced,1 limiting the oropharyngeal space21 and pre-
venting alignment of the oral, pharyngeal, and tracheal axes.3
These characteristics have been shown to contribute to the
worsening of Cormack–Lehane grades by direct laryngoscopy,2
thereby increasing the rate of failure of tracheal intubation.1 3 In
the present study, mouth opening after application of the neck
collar was significantly reduced and the modified Cormack–
Lehane grade also decreased. Limited mouth opening and the
oropharyngeal space can hamper the insertion of an adult-sized
blade of the Pentax-AWS into the mouth and cause injury to the
teeth and mouth, resulting in failure of tracheal intubation.22 23
Moreover, it requires optimal positioning of the glottis in the
centre of the video screen, prompting the anaesthetist to per-
form scooping movements, consequently resulting in multiple
attempts.18 20 21 23 The thickness of the standard adult blade of a
Pentax-AWS is 18 mm, requiring an inter-incisor gap of 25 mm
for smooth manipulation of the blade.26 27 A paediatric-sized
blade is the thinnest among the Pentax-AWS blades, and thus it
would allow for easier insertion into the mouth and better
manoeuvrability in a narrow oropharyngeal space than the
adult-sized blade. Moreover, when used in combination with a
fibrescope, optimal positioning might become non-essential,
thereby reducing attempts for positioning. Given that easy in-
sertion and fewer scooping movements are desirable in patients
with potential cervical spine injury, the paediatric blade of the
Pentax-AWS was chosen to overcome these difficulties. In prac-
tice, it was easy to insert and position the tip of the paediatric
blade of the Pentax-AWS into the pharynx. Moreover, the scoop-
ing movement for the advancement of the paediatric blade was
confined to one attempt, and fibreoptic tracheal intubation was
 996 | Kim et al.
Enrollment Assessed for eligibility (n = 99)
Randomized (n=90)
Allocation
Allocated to a control group (n= 45)
Received allocated intervention (n=45)
Did not receive allocated intervention (n= 0)
Follow-Up
Lost to follow-up (n = 0)
Analysis
Analysed (n=45)
Excluded from analysis (n= 0)
Fig 1 CONSORT flow diagram of recruitment and assessment of study participants.
feasible regardless of whether the epiglottis was elevated. There
was some concern that the shorter paediatric blade might im-
pinge on the posterior third of the tongue and force the tongue
backwards towards the oropharynx, thereby impeding the bron-
choscopy, but there were no such issues when the paediatric
blade of the Pentax-AWS was used. The combined use of the
paediatric blade of the Pentax-AWS and a fibreoptic broncho-
scope was a feasible option in patients with limited mouth
opening.
In patients wearing neck collars because of potential cervical
spine injuries, an alternative method is required instead of con-
ventional direct laryngoscopy.3 The optimal method for guaran-
teeing a high success rate of intubation while minimizing
cervical spine movement remains under debate.1 In addition to
being a reliable method, fibreoptic tracheal intubation might be
a good alternative for minimizing cervical spine movements.4
Although awake fibreoptic tracheal intubation is the most reli-
able method, fibreoptic tracheal intubation can also be per-
formed under general anaesthesia upon consideration of
Excluded (n=9)
Not meeting inclusion crtieria (n = 2)
Declined to participate (n =7)
Other reaons (n =0)
Allocated to a block group (n = 45)
Received allocated intervention (n =45)
Did not receive allocated intervention (n = 0)
Lost to follow-up (n =0)
Analysed (n = 45)
Excluded from analysis (n = 0)
various conditions, such as the level of emergency, patient co-
operation, feasibility of mask ventilation, or the provider’s fa-
miliarity and experience with the procedure.28 29 One problem
with fibreoptic orotracheal intubation under general anaesthe-
sia is that the loss of pharyngeal muscle tone reduces the oro-
pharyngeal space for the passage of the fibreoptic bronchoscope
and makes it difficult to maintain the fibreoptic bronchoscope
in the midline while advancing its tip into the pharynx and the
laryngeal inlet.5–7 Consequently, specific oral airway or addi-
tional manoeuvres to open the pharyngeal airway are com-
monly required.7 9 In the present study, while applying the
Ovassapian airway, the fibreoptic view was frequently ob-
structed and identification of the midline was difficult. Only
when jaw thrust was applied in 91% of the patients of Group
OVA-FOB was a laryngeal view obtained. On the contrary, in all
patients of Group AWS-FOB, the midline was easily identified
because the epiglottis or laryngeal inlet was obtained on the
screen of the Pentax-AWS without additional manoeuvres (e.g.
jaw thrust), and the gel-coated fibreoptic bronchoscope could be
 Paediatric Pentax-AWS and fibreoptic intubation | 997

scale, which scored difficulty in manipulating the fibreoptic

Table 1 Patient characteristics and airway assessment. Data bronchoscope for tracheal intubation, the combined use of the
are represented as the mean (SD) or number. C-L grade, modi-
two devices was also significantly easier than the method used
fied Cormack–Lehane grade; Group AWS-FOB, tracheal intuba-
tion with the paediatric blade of the Pentax-AWS and the in Group OVA-FOB. Therefore, the combined use of the paediat-
fibreoptic bronchoscope; Group OVA-FOB, tracheal intubation ric blade of the Pentax-AWS and a fibreoptic bronchoscope
with Ovassapian airway and the fibreoptic bronchoscope could be a very useful alternative method, allowing quicker and
easier fibreoptic tracheal intubation in patients with neck
Group Group collars.
OVA-FOB AWS-FOB When a neck collar is applied, neck flexion, extension, and
(n¼45) (n¼45) rotation are possible to some extent,30 31 even with the use of
manoeuvres to limit neck movement. The fibreoptic broncho-
Age (yr; median [range]) 43 [29–57] 42 [25–60]
scope is suitable for minimizing cervical movements; however,
Sex (male/female) 20/25 20/25
the present study emphasizes how essential jaw thrust is dur-
Weight (kg) 66 (11) 65(11)
Height (cm) 165 (9) 165 (8)
ing fibreoptic tracheal intubation in patients with neck collars.
ASA grade (I/II) 40/5 43/2 Although the effect of jaw thrust on movement of the cervical
Neck circumference (cm) 38 (4) 38 (4) spine has been reported to be better than head tilt–chin lift in
Mouth opening (cm) patients with neck collars,32 it was not easy to apply the jaw
Before neck collar 4.0 (3.3) 3.8 (0.7) thrust efficiently without lifting the chin. The Pentax-AWS has
After neck collar 2.4 (0.3) 2.5 (0.4) been reported to produce less cervical spine movement.33
C-L grade (I/IIa/IIb/III/IV) by direct laryngoscope Moreover, in the present study, we also demonstrated that the
Before neck collar 18/12/14/1/0 21/13/11/0/0 ventral force of the Pentax-AWS was unnecessary, which might
After neck collar 3/4/23/15/0 3/12/22/8/0 make the tip of the fibreoptic bronchoscope passing through the
tube channel of the paediatric blade of the Pentax-AWS contact
the posterior portion of the tongue, thereby intruding on the ad-
vancement of the fibreoptic bronchoscope. We conclude that
the advancement alone of the paediatric blade of the Pentax-
AWS into the patient’s pharynx without a ventral (lifting) force
Table 2 Airway management data. Data are represented as the
median (interquartile range) or number (percentage). The time
could limit the movement of the cervical spine, although cervi-
to tracheal intubation and NRS difficulty score were compared cal movements were not measured in the present study.
using a Mann–Whitney U-test. Group AWS-FOB, tracheal intu- As a conduit for fibreoptic tracheal intubation in patients
bation with the paediatric blade of the Pentax-AWS and the with limited neck movement, a laryngeal mask airway has also
fibreoptic bronchoscope; Group OVA-FOB, tracheal intubation been reported to be useful.8 34 35 It can be inserted without mov-
with Ovassapian airway and the fibreoptic bronchoscope; NRS
ing the cervical spine, and the use of a fibrescope through a la-
difficulty score, difficulty of fibreoptic bronchoscope manipula-
tion as a numerical rating scale
ryngeal mask airway is associated with an excellent success
rate for tracheal intubation.36 37 In addition, unlike the paediat-
Group Group P-value ric blade of Pentax-AWS, it allows for ventilation to continue
OVA-FOB AWS-FOB while attempting to intubate the trachea with a fibrescope. Its
(n¼45) (n¼45) limitations include a limited tracheal tube size and difficulty
with the removal of the laryngeal mask airway leading to an in-
Time to tracheal intubation (s) 50 (43–63) 32 (24–43) <0.001 advertent extubation.38 In contrast, the removal of the paediat-
Success rate on the first 44 (98) 45 (100) 1.000 ric blade of the Pentax-AWS after the insertion of a fibrescope
attempt into the trachea was easy, and an adult-sized tracheal tube
Jaw thrust <0.001 could be advanced over the fibreoptic bronchoscope.
No use 4 (9) 44 (98)
This study had several limitations. First, there was a poten-
Use under neck collar 39 (87) 0 (0.0)
tial bias because the anaesthetists could not be blinded to the
Use after removal of 2 (4) 1 (2)
group allocation. Second, the fibreoptic bronchoscope procedure
neck collar
was performed by only one experienced anaesthetist; therefore,
Mucosal damage 4 (9) 3 (7) 1.000
the assessment of the difficulty score reflected only one per-
NRS difficulty score 5 (4–6) 4 (3–5) 0.005
son’s judgement. This finding might therefore not be translat-
able to less experienced users. However, we believe that the use
of the paediatric blade of the Pentax-AWS for passing of the
fibreoptic bronchoscope would be easy even for less experi-
kept straight within the channel and passed smoothly through enced users. Third, the patients in this study were healthy pa-
the tube channel of the paediatric blade of the Pentax-AWS. tients in whom the neck collar simulated a difficult airway. This
Especially in patients where the epiglottis was elevated on the scenario is different from clinical practice, in which the pa-
screen, the advancement of the fibreoptic bronchoscope into tient’s airways might be oedematous, modified, or not clear be-
the trachea was so easy that even users with less experience cause secretions of blood or sputum. Fourth, the combined
and training could perform the procedure. In patients where the method used in this study requires two operators.
anterior wall of the epiglottis was visible on the screen, the la- In conclusion, the combined use of the paediatric blade of
ryngeal inlet was visible on the eyepiece of the fibreoptic bron- the Pentax-AWS and a fibreoptic bronchoscope enables rapid
choscope when the tip of the bronchoscope was manipulated in intubation while minimizing the use of external manoeuvres in
an upward (anterior) direction after passing between the epi- patients with limited mouth opening and cervical spine immo-
glottis and pharyngeal wall, and advancement of the fibreoptic bilization by a semi-rigid neck collar, compared with the
bronchoscope was possible. According to the numerical rating Ovassapian airway and fibreoptic bronchoscope.
 998 | Kim et al.
Authors’ contributions
Study design/planning: Y.J.C., D.H.K., J.Y.Y.
Study conduct: Y.J.C., D.H.K., S.Y.H.
Data analysis: J.Y.Y., S.Y.H.
Writing the manuscript: D.H.K., Y.J.C.
Revising the manuscript: D.H.K., J.Y.Y., S.Y.H., Y.J.C..
Declaration of interest
None declared.
Funding
This research received no specific grants from any funding
agencies in the public, commercial, or not-for-profit sectors.
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Handling editor: Tak Asai