Airway Course Research Articles

New tools for learning airway management

INTRODUCTION Game-based learning, also called edutainment, has been promoted as an alternative to the unidirectional, passive teaching of traditional medical education. Solving enigmas and problems through creativity and critical thinking, which is encapsulated in ‘escape rooms’, has been adapted to teach medicine as a way to enhance the mental models of proceeding. We considered an educational escape room as an activity to promote teaching and training in airway management, integrating knowledge, technical and nontechnical skills and collaborative teamwork during crisis situations. METHODS No published experience on this topic was found. Therefore, we created an educational escape room focused on airway management. We describe the steps undertaken from the design and development of the escape room process (as part of the curriculum of an international airway course) to the results of a survey completed by the participants at the end of the escape room process. RESULTS Satisfaction with the experience was rated at least 8 points (0 to 10 numerical rating scale) by 80% of the 147 course participants. Two thirds also rated the experience as at least 8 points (0 to 10 Likert scale) as being helpful in improving behaviour in real cases, and enhance organisational teamwork skills. CONCLUSION The airway escape room was feasible for training in airway management. Participants rated it as valuable to gain team competencies. The experience encourages further development and its possible use in other clinical settings.

Using cognitive load theory to develop an emergency airway management curriculum: the Queen's University Mastery Airway Course (QUMAC).

Emergency airway management requires the simultaneous coordination of clinical reasoning and therapeutic interventions in the complex and time-sensitive setting of emergency resuscitation. The cognitive demand associated with these situations is invariably high and must be taken into consideration when designing training programs for this core professional competency. The four-component instructional design model (4C/ID), based on cognitive load theory, was used to develop a 1-year longitudinal airway management curriculum for Emergency Medicine residents. The simulation-based curriculum was designed with the goal of facilitating the construction and automation of schemas by individual residents in preparation for the high cognitive demand associated with emergency airway management in the clinical environment.

99 A Fresh Model in the Vehicles for Learning: Redesigning an Established, Traditional Airway Course to be Delivered in a Multi-Site Hybrid Format in the COVID-19 Era

The Royal College of Anaesthetists (RCOA) stipulates that anaesthetists should be able to use advanced/novel airway management techniques. The RCOA-accredited annual Challenging Airway Course in Northern Ireland is a staple of the calendar, providing an opportunity for all those involved in airway management to gain, refresh and replenish skills. Having already been cancelled in 2020 due to the pandemic, there was a strong appetite, particularly within the trainee body, that it should be staged in some form this year.The aim of the study was to deliver a high-quality course that outlined the theory behind airway management, without loss of the hands-on aspects of equipment/techniques, to a large candidate group in a COVID-19 safe environment.Alteration of the face-to-face course to run in a hybrid multi-site format with both online components and practical workstations.The course was delivered simultaneously in real time across the multiple deanery teaching hospitals. There was a central hub from which the course lead could synchronize timings/broadcast recorded material. As part of contingency plans for any unanticipated technical difficulties, lectures were pre-recorded and played for candidates on the day. These were punctuated with four practical workstations that mandated two delegates per station. Additionally, some content was recorded for viewing online as pre-course material and new simulation videos of a failed intubation drill and the subsequent debrief were also created. For some unable to attend site locations, a fully virtual experience was also an option. These modifications allowed us to: maximize attendance without breaching social distancing guidelines; retain the hands-on aspect of using equipment/techniques and also maintain an excellent faculty to candidate ratio to allow ample time for practising/asking questions. The pre-course material also empowered the candidates to feel better prepared for the day. Post-course anonymous feedback was completed by the vast majority of delegates and was overwhelmingly positive. Pre-course material, facilities, content, lectures, simulations and workshops were rated highly. The use of airway exchange catheters was mentioned as the introduction of a new skill for many delegates. Apart from one candidate, no one had attended any RCOA-accredited airway events in the preceding year but 100% of the candidates would recommend this course to their peers. Amidst challenging times, we successfully restyled an established and respected course. The novel hybrid multi-site format allowed a larger number of candidates to network face-to-face and gain knowledge/practical skills within a COVID-safe environment. Until such times as ‘normality’ and perhaps beyond, this may be a new formula for learning.

Randomised controlled trial in cadavers investigating methods for intubation via a supraglottic airway device: Comparison of flexible airway scope guided versus a retrograde technique.

A supraglottic airway device (SAD) may be utilised for rescue re-oxygenation following a failed attempt at endotracheal intubation with direct or video laryngoscopy. However, the choice of subsequent method to secure a definitive airway is not clearly established. The aim of the present study was to compare two techniques for securing a definitive airway via the in-situ SAD. A randomised controlled trial was undertaken. The population studied was emergency physicians (EPs) attending a cadaveric airway course. The intervention was intubation through a SAD using a retrograde intubation technique (RIT). The comparison was intubation through a SAD guided by a flexible airway scope (FAS). The primary outcome was time to intubation. The trial was registered with ANZCTR.org.au (ACTRN12621000995875). Four EPs completed intubations using both methods on four cadavers for a total of 32 experiments. The mean time to intubation was 18.2s (standard deviation 8.8) in the FAS group compared with 52.9s (standard deviation 11.7) in the RIT group; a difference of 34.7s (95% confidence interval 27.1-42.3, P < 0.001). All intubations were completed within 2min and there were no equipment failures or evidence of airway trauma. Successful tracheal intubation of cadavers by EPs is achievable, without iatrogenic airway trauma, via a SAD using either a FAS or RIT, but was 35 s quicker with the FAS.

Comparing methods to secure a tracheal tube placed via a surgical cricothyroidotomy: a randomised controlled study in cadavers

ObjectiveIn the ‘can’t intubate can’t oxygenate’ scenario, techniques to achieve front of neck access to the airway have been described in the literature but there is a lack of guidance on the optimal method for securing the tracheal tube (TT) placed during this procedure. The aim of this study was to compare three different methods of securing a TT to prevent extubation following a surgical cricothyroidotomy.MethodsA randomised controlled trial was undertaken. The population studied were emergency physicians (EPs) attending a cadaveric airway course. The intervention was securing a TT placed via a surgical cricothyroidotomy by suture. The comparison was securing the TT using fabric tape with two different tying techniques. The primary outcome was the force required to extubate the trachea. The trial was registered with ANZCTR.org.au (ACTRN12621000320853).Results17 emergency physicians completed intubations using all three of the securing methods on 12 cadavers for a total of 51 experiments. The mean extubation force was 6.54 KG (95 % CI 5.54–7.55) in the suture group compared with 2.28 KG (95 % CI 1.91–2.64) in the ‘Wilko tie’ group and 2.12 KG (95 % CI 1.63–2.60) in the ‘Lark’s foot tie’ group; The mean difference between the suture and fabric tie techniques was significant (p < 0.001).ConclusionsFollowing a surgical cricothyroidotomy in cadavers, EPs were able to effectively secure a TT using a suture technique, and this method was superior to tying the TT using fabric tape.

The introduction of a paediatric ENT and anaesthesia skills course in Kilimanjaro Christian Medical Centre hospital, (KCMC), Moshi, Tanzania

Human factors and a safe operating theatre environment are of paramount importance, wherever surgery is undertaken. The majority of patients in sub-Saharan Africa do not yet have access to safe surgery. The Paediatric ENT Skills and Airway Course introduced and evaluated here was designed to improve outcomes and safety in a typical East African environment. The lectures, tutorials and practicals covered technical and non-technical skills. Responses from pre- and post-course questionnaires were evaluated as an initial surrogate for effectiveness of this course. The latter showed improvement in all taught skills and found universal recommendation. The course had been established to try to minimise morbidity and mortality after paediatric surgery at our institution, KCMC. We encouraged team co-operation in the care of patients, and recommend other centres consider similar courses building on human factors for safer operating theatre working practices.

The use of USB endoscope (Borescope) as an educational tool and a guide for tracheal intubation − a preliminary report

Background In spite of the presence of multiple video laryngoscopes in the market, financial restrains are present that prevent its routine use in many practices.Methods The endoscope USB camera was inserted alongside with a stylet in a conventional endotracheal tube which could be inserted orally keeping it in midline (7 or 7.5 cuffed oral endotracheal tube), and sterile k-y gel was used to facilitate the insertion of the stylet and/or the borescope. This was used for 25 oral intubations in manikin and oral intubation in 10 patients.Results Oral intubation trials on manikin were done by 25 physicians after their completion of airway course as its last session. All were anesthesiologists except one emergency room physician. A total of 14 (56%) physicians were successful to orally intubate the manikin in the first attempt. Moreover, 10 (40%) physicians were successful to orally intubate the manikin in the second attempt with verbal guidance, except one who needed manual assistance, and one physician was successful to orally intubate the manikin in the third attempt with verbal assistance. The intubated 10 patients were all of Mallampati 1 or 2, where seven were intubated on the first attempt, two on the second attempt, and one failed.Conclusion Borescope can be used as a cheap option for airway management and its training. Randomized studies need to be done for its evaluation compared with other video laryngoscopy devices.

A Multispecialty Critical Airway Simulation Course for Medical Students.

To develop a novel multispecialty simulation-based course that teaches both technical and nontechnical skills in the management of adult and pediatric critical airways to graduating medical students and 2) to encourage a collaborative, multispecialty approach to the management of a difficult airway amongst fourth-year medical students who have enrolled in otolaryngology, anesthesia, and emergency medicine residency programs. Fourth-year medical student who had matched into otolaryngology, anesthesia, and emergency medicine participated in an intensive half-day course consisting of a series of hands-on skills stations with increasing complexity, followed by simulated complex patient scenarios designed for shared management of airway emergencies. Participants completed questionnaires prior to and immediately after the course. Fischer's exact test was utilized to compare data between the precourse and postcourse surveys. Free-text responses were qualitatively assessed to inform course development. Thirty-four medical students were enrolled (6 otolaryngology, 15 anesthesia, 13 emergency medicine), and 30 students completed both surveys. Fisher's exact test demonstrated improved confidence (P < .05) for every skill. More than 85% of participants strongly agreed or agreed that the intervention was useful in developing their knowledge, technical skills, and self-confidence and in improving clinical performance prior to residency. This critical airway course introduces a multispecialty simulation-based course designed to impart graduating medical students with the necessary knowledge, skills, and behaviors for critical airway management while fostering interprofessional collaboration. Our course was successful in improving confidence and was perceived as useful in developing knowledge, technical skills, self-confidence, and clinical performance prior to residency. NA Laryngoscope, 131:1482-1486, 2021.

A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities

BackgroundThere is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult—not emergency—intubation. In this study, we...

Enhanced Experiential Learning in Airway Management: Surgical Modification of Cadavers.

Failure of airway management remains a significant source of morbidity and mortality. Advanced airway management has been addressed effectively by simulation-based training. However, simulation of difficult airways in manikins is limited by the pre-set conditions provided by the manufacturer. Life-like conditions in the form of the softness of the tissue and true anatomy as seen in cadaver models are needed to create simulated models with a closer resemblance to real patients. The goal of this study was to determine the feasibility of simulating difficult airway from submandibular abscess in cadaver models by surgical modification of the cadaver heads for use in enhanced experiential learning of the management of difficult airways. The cadaver heads were modified surgically to simulate a submandibular abscess. The models were used in an airway course where participants provided feedback on the realistic nature of the model and its benefits for difficult airway training. The ease of tracheal intubation of the models with the assistance of video laryngoscopy was assessed. The modified cadavers were acceptable in simulating difficult airway as demonstrated by the feedback from the participants. All participants (100% [95% confidence interval = 89.1%-100%]) found the models to be realistic and beneficial for difficult airway training. A good proportion (56.3%) felt that the intubation technique was made easier with the video laryngoscopy. Cadavers can be modified to simulate pathologies associated with difficult airways. These models can be used to enhance experiential learning and the management of difficult airways.

An Innovative Inexpensive Portable Pulmonary Edema Intubation Simulator.

An Innovative Inexpensive Portable Pulmonary Edema Intubation Simulator.

The Pediatric Multidisciplinary Difficult Airway Course - an innovation in airway education

The Pediatric Multidisciplinary Difficult Airway Course - an innovation in airway education

Michigan Medicine: The University of Michigan Head and Neck Anesthesiology and Advanced Airway Management Fellowship

Michigan Medicine: The University of Michigan Head and Neck Anesthesiology and Advanced Airway Management Fellowship

The importance of technical skills assessment during an airway foreign body removal course

PurposeSurgical simulation has proven useful in training for high-acuity, low frequency events such as airway foreign body removal (AWFBR). Studies have supported the role of simulation to improve trainee confidence and technical proficiency, but rigorous methodology is often lacking.Through a pilot study, we sought to evaluate the feasibility and utility of two-view video capture for rigorous assessment of trainee skill in an educational course setting. MethodsParticipants were asked to perform 1) self-assessment surveys using 5- point Likert scale questions and 2) rigid bronchoscopy with AWFBR on intubation trainers, at the beginning and end of a multi-institution airway course. Video was collected from endoscopic and wide-angle body cameras. The videos were blinded and evaluated in random order by two expert reviewers using a 5-point pediatric airway endoscopy specific objective structured assessment of technical skills (OSATS) instrument. ResultsFourteen trainees submitted pre- and post-course surveys, and eight of these also had complete video data. Faculty feedback indicated the importance of pre- and post-course AWFBR recordings for real-time trainee feedback and post-course curricular refinement. Survey data showed an increase in confidence for AWFBR from 2.0 to 3.3 (p = 0.05). Average OSATS scores increased from 1.84 to 2.58 but this did not reach significance (p = 0.51). Paired improvements in confidence exceeded improvements in OSATS scores (1.29 vs. 0.18, p = 0.058). ConclusionsRigorously evaluated two-view video capture was feasible in an educational course setting. The course resulted in improvements in confidence to a greater degree than OSATS scores. This supports the importance of assessing course impact and refining curricula using all available data including objectively assessing technical skills.

Survival and Decannulation after Infant Tracheostomy

Background: Mortality and airway morbidity immediately following tracheostomy, (trach),) are well documented in the literature. There are few reports about morbidity beyond the airway or longer-term course after tracheostomy. Objective: To compare timing of trach, decannulation rates, and time to decannulation based on the initial indication for trach. Methods: We performed a large retrospective study of children undergoing tracheostomy before 1 year of age at a single quaternary center …

Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program

A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001. Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course.

A Multidisciplinary Approach to a Pediatric Difficult Airway Simulation Course.

Objective To design and assess an advanced pediatric airway management course, through simulation-based team training and with multiple disciplines, to emphasize communication and cooperation across subspecialties and to provide a common skill set and knowledge base. Methods Trainees from anesthesiology, emergency medicine, critical care, pediatric surgery, and otolaryngology at a tertiary children's hospital participated in a 1-day workshop emphasizing airway skills and complex airway simulations. Small groups were multidisciplinary to promote teamwork. Participants completed pre- and postworkshop questionnaires. Results Thirty-nine trainees participated over the 3-year study period. Compared with their precourse responses, participants' postcourse responses indicated either agreement or strong agreement that the multidisciplinary format (1) helped in the development of team communication skills and (2) was preferred over single-discipline training. Improvement in confidence in managing critical airway situations and in advanced airway management skills was significant ( P < .05). Eighty-one percent of participants had improved confidence in following the hospital's critical airway protocol, and 64% were better able to locate advanced airway management equipment. Discussion Multiple subspecialists manage pediatric respiratory failure, where successful care requires complex handoffs and teamwork. Multidisciplinary education to teach advanced airway management, teamwork, and communication skills is practical and preferred by learners and is possible to achieve despite differences in experience. Future study is required to better understand the impact of this course on patient care outcomes. Implications for Practice Implementation of a pediatric difficult airway course through simulation-based team training is feasible and preferred by learners among multiple disciplines. A multidisciplinary approach exposes previously unrecognized knowledge gaps and allows for better communication and collaboration among the fields.

Abstract PR539

Background & Objectives: Difficult airway management guidelines recommend a specific learning program for improvement of technical and non-technical airway skills. Live tissue training involves the use of animals to provide realistic training programs, better simulating life threatening scenarios. The aim of the prospective study was to describe the motivations for attending the airway training and the long-term consequences for the anaesthetists practices. Materials & Methods: Since 2012, a biannual airway training course has been organised in Ponderas Training Centre,Bucharest, Romania. It is a two day course accredited by the Romanian College of Physicians with10 CME points and consists of 4 hours lectures, of 4 hours training on mannequins and 8 hours training on anaesthetized pigs. A feedback form was given to all participants after each course, and in January 2016 a survey of all participants in the last 4 years was conducted. The anonymous feedback form evaluated the instructors regarding the content, the form of presentations, the value of discussions, the practical training on manniquins and on live animals. The survey sent included questions about motivations for the educational programme and the impact of the course on personal airway management developments and practice changes, as well as the implementing of their acquired knowledge and skills. Results: The airway course participants (n=151) response rate was 100% for the feedback form and 79% for the survey. The distribution of the participants was:67 consultants,62 specialists and 22 trainees in anaesthesia and intensive care with a median age of 37years. 87 participants were from Bucharest and 64 from other Romanian cities.The necessary equipment for bronchoscopy was available in 60% of the hospitals where the participants worked but they rated as insufficient their training in supraglottic devices, airway exchangers, fiberoptic intubation and surgical airway.The practical workshop on live animals was ranked with maximum score in 100 % of cases, 97 %respondents considering training on animals more reliable than on mannequins. The first 2 motivations in the survey were “to learn technical skills-especially bronchoscopy” and to “use new devices”. The survey confirmed a practice change in 91% of the respondents but only 30 %were planning on implementing the new acquired knowledge in their institutions. Finally 87 % of the respondents answered they were more confident in their airway management practice. Conclusion: Training on live animals seemed to better simulate the airway practice and expedite the acquisition of the airway skills, aknowledging an improvement in the anaesthetists airway practice. The training for invasive procedures had a special relevance where the lack of technical skills interfere with acute psychological stress. Disclosure of Interest: None declared

Abstract PR582

Case report: Background: A coordinated difficult airway (DA) management program at University of Rochester Medical Center (URMC) was necessary to prevent harm and adverse outcomes from DA management outside of the operating room, since there were no sufficient resources available for DA management during the off-hours and out-of-OR locations. Our goals were to improve quality of difficult and emergency airway management at out-of-OR locations, organize paging system to systematize arrival of multiple experienced personnel, and decrease the time to mobilize equipment. The Johns Hopkins Medicine (JHM) Difficult Airway Response Team (DART) Program is multidisciplinary, comprehensive DA program that reported no airway management-related deaths, malpractice claims or sentinel events in their first 5 years. URMC adapted and implemented the JHM DART Program for the management of DA outside the operating room. Methods: DART Steering Committee was established and included representatives from five clinical departments, including anesthesiology, otolaryngology, trauma surgery, critical care and emergency medicine. DART Steering Committee met regularly over the course of three months to lay the groundwork for implementation of the DART Program. JHM DART Program Oversight Team provided guidance in adapting the JHM DART Program to align with resources at URMC. Efforts focused on: determining the composition of the team; developing criteria for summoning the team; establishing a unified telecommunications response system, developing a fully equipped DA carts, educating staff about the existence of DART and criteria for when to summon it. JHM DART Program formal consultation which included on-site visits, on-going conference calls, and sharing of DART Tool Box documents for URMC DART Program modification facilitated timeline for a comprehensive program. Results: URMC’s innovative members adapted the JHM DART Program within 3 months of initiating this project. URMC DART Team was established and implemented with providers from five departments and DART Policy was accepted with instructions about DART activation, equipment delivery, and providers’ responsibility. Educational component of DART Program, Multidisciplinary Difficult Airway Course, was implemented for senior residents and fellows from five DART Departments targeting 100% participation. Conclusion: Implementation or the DART Program at URMC established the team which is capable of delivering the highest-quality and safest patient-centered care during difficult airway management at our institution. First year URMC results will be analyzed and collaborative lessons learned will be shared with providers wanting to adapt a DART Program to their institution. Disclosure of Interest: None declared

Techniques for Improving Video Laryngoscopy With a Hyperangulated Blade.

Video laryngoscopy (VL) is being employed increasingly for emergency airway management. The original GlideScope advanced video laryngoscope has a hyperangulated blade with a 60-degree curvature intended to improve glottic exposure. This hyperangulated shape usually requires the use of a correspondingly curved stylet, such as the GlideRite stylet, to guide the endotracheal tube to the laryngeal inlet. If a curved stylet is not available, you can bend a malleable stylet to the same degree as the blade you are using. While some studies have shown better first-pass success rates with VL compared with direct laryngoscopy, the technique can be frustrating for users of standard nonvideo nonhyperangulated blades.1-5 A link to the video is given below that highlights three tips/techniques that we have used in our airway course to teach emergency medicine residents how to best use the GlideScope. First, a common error after the GlideScope is placed in the mouth is that the blade is pushed in too deeply. This position can impair placement of the tube, so the GlideScope should be pulled back about 2 cm. This back-up maneuver will create more room to pass the endotracheal tube. Second, the endotracheal tube with stylet should be held at its distal end rather than in the middle of the tube, as is typically done for standard nonvideo laryngoscopic intubations. This technique allows better manipulation and control of the direction of the tip. Then the tip of the endotracheal tube should be advanced into the inlet until it is just visualized on the screen. Third, the equipment should be stabilized by grasping both the endotracheal tube and the GlideScope blade in one hand while watching the GlideScope screen. The endotracheal tube is then advanced into the trachea in a three-step process: Once the endotracheal tube tip is placed in the inlet, 1) the stylet end should be pulled back slightly, 1 or 2 cm, usually with the thumb while 2) simultaneously advancing the tip between the cords. Watch for the tip of the stylet to reach the upper corner of the video screen, then 3) continue to advance the endotracheal tube until its tip passes between the cords. Then completely remove the stylet and secure the tube in place. Video can be accessed at vimeo.com at: https://vimeo.com/164775680?lite=1 Password: password