Endotracheal Intubation Performance Research Articles

Market Analysis of Video Laryngoscopy Equipment for the Role 1 Setting.

Airway compromise is the second leading cause of potentially preventable prehospital combat death. Endotracheal intubation (ETI) remains the most common role 1 airway intervention. Video laryngoscopy (VL) is superior to direct laryngoscopy (DL) for first-attempt intubation, especially in less-experienced providers and for trauma patients. The cost has been a major challenge in pushing VL technology far-forward; however, the cost of equipment continues to become more affordable. We conducted a market analysis of VL devices under $10,000 for possible options for role 1. We searched Google, PubMed, and the Food and Drug Administration database from August 2022 to January 2023 with a combination of several keywords to identify current VL market options under $10,000. After identifying relevant manufacturers, we then reviewed individual manufacturer or distributor websites for pricing data and system specifications. We noted several characteristics regarding VL device design for comparison. These include monitor features, size, modularity, system durability, battery life, and reusability. When necessary, we requested formal price quotes from respective companies. We identified 17 VL options under $10,000 available for purchase, 14 of which were priced below $5,000 for individual units. Infium (n = 3) and Vimed Medical (n = 4) provided the largest number of unique models. VL options under $10,000 exist in both reusable and disposable modalities. These modalities included separate monitors as well as monitors attached to the VL handle. Disposable options, on a per-unit basis, cost less than reusable options. Several VL options exist within our goal price point in both reusable and disposable options. Clinical studies assessing the technology performance of ETI and deliberate downselection are needed to identify the most cost-effective solution for role 1 dispersion.

A novel algorithm-driven hybrid simulation learning method to improve acquisition of endotracheal intubation skills: a randomized controlled study

BackgroundSimulation-based training is a clinical skill learning method that can replicate real-life situations in an interactive manner. In our study, we compared a novel hybrid learning method with conventional simulation learning in the teaching of endotracheal intubation.MethodsOne hundred medical students and residents were randomly divided into two groups and were taught endotracheal intubation. The first group of subjects (control group) studied in the conventional way via lectures and classic simulation-based training sessions. The second group (experimental group) used the hybrid learning method where the teaching process consisted of distance learning and small group peer-to-peer simulation training sessions with remote supervision by the instructors. After the teaching process, endotracheal intubation (ETI) procedures were performed on real patients under the supervision of an anesthesiologist in an operating theater. Each step of the procedure was evaluated by a standardized assessment form (checklist) for both groups.ResultsThirty-four subjects constituted the control group and 43 were in the experimental group. The hybrid group (88%) showed significantly better ETI performance in the operating theater compared with the control group (52%). Further, all hybrid group subjects (100%) followed the correct sequence of actions, while in the control group only 32% followed proper sequencing.ConclusionsWe conclude that our novel algorithm-driven hybrid simulation learning method improves acquisition of endotracheal intubation with a high degree of acceptability and satisfaction by the learners’ as compared with classic simulation-based training.

Endotracheal intubation of COVID-19 patients by paramedics using a box barrier: A randomized crossover manikin study.

BackgroundIn the prehospital setting, endotracheal intubation (ETI) may be required to secure the coronavirus disease 2019 (COVID-19) patient airway. It has been suggested that the use of a protective barrier can reduce possible aerosol delivery from patients to clinicians during ETI. We sought to assess the performance of ETI by paramedics wearing personal protective equipment with and without the use of a box barrier.MethodsA randomized, crossover simulation study was performed in a simulation laboratory. Study participants were 18 paramedics actively working in the clinical environment. Participants’ performance of ETI via direct laryngoscopy (DL) with and without the use of a box barrier was assessed. The sequence of intubation was randomized to either BoxDL-first or DL-first. The primary outcome was the success rate of ETI on first-attempt. The secondary and tertiary outcomes were ETI success rates on three attempts and total intubation time, respectively.ResultsThere were no differences between the DL group and the BoxDL group in one-attempt success rates (14/18 vs 12/18; P = 0.754), and in overall success rates (16/18 vs 14/18; P = 0.682). The mean (standard deviation) of the total intubation times for the DL group and the BoxDL group were 27.3 (19.7) seconds and 36.8 (26.2) seconds, respectively (P < 0.015).ConclusionsThe findings of this pilot study suggest that paramedics wearing personal protective equipment can successfully perform ETI using a barrier box, but the intubation time may be prolonged. The applicability of these findings to the care of COVID-19 patients remain to be investigated.

An Intelligent Augmented Reality Training Framework for Neonatal Endotracheal Intubation.

Neonatal Endotracheal Intubation (ETI) is a critical resuscitation skill that requires tremendous practice of trainees before clinical exposure. However, current manikin-based training regimen is ineffective in providing satisfactory real-time procedural guidance for accurate assessment due to the lack of see-through visualization within the manikin. The training efficiency is further reduced by the limited availability of expert instructors, which inevitably results in a long learning curve for trainees. To this end, we propose an intelligent Augmented Reality (AR) training framework that provides trainees with a complete visualization of the ETI procedure for real-time guidance and assessment. Specifically, the proposed framework is capable of capturing the motions of the laryngoscope and the manikin and offer 3D see-through visualization rendered to the head-mounted display (HMD). Furthermore, an attention-based Convolutional Neural Network (CNN) model is developed to automatically assess the ETI performance from the captured motions as well as identify regions of motions that significantly contribute to the performance evaluation. Lastly, augmented user-friendly feedback is delivered with interpretable results with the ETI scoring rubric through the color-coded motion trajectory that classifies highlighted regions that need more practice. The classification accuracy of our machine learning model is 84.6%.

Automated Assessment of Neonatal Endotracheal Intubation Measured by a Virtual Reality Simulation System.

Manual assessment from experts in neonatal endotracheal intubation (ETI) training is a time-consuming and tedious process. Such subjective, highly variable, and resource-intensive assessment method may not only introduce inter-rater/intra-rater variability, but also represent a serious limitation in many large-scale training programs. Moreover, poor visualization during the procedure prevents instructors from observing the events occurring within the manikin or the patient, which introduces an additional source of error into the assessment. In this paper, we propose a physics-based virtual reality (VR) ETI simulation system that captures the entire motions of the laryngoscope and the endotracheal tube (ETT) in relation to the internal anatomy of the virtual patient. Our system provides a complete visualization of the procedure, offering instructors with comprehensive information for accurate assessment. More importantly, an interpretable machine learning algorithm was developed to automatically assess the ETI performance by training on the performance parameters extracted from the motions and the scores rated by experts. Our results show that the leave-one-out-cross-validation (LOOCV) classification accuracy of the automated assessment algorithm is 80%, which indicates that our system can reliably conduct a consistent and standardized assessment for ETI training.

Automated Assessment System with Cross Reality for Neonatal Endotracheal Intubation Training.

Neonatal endotracheal intubation (ETI) is a resuscitation skill and therefore, requires an effective training regimen with acceptable success rates. However, current training regimen faces some challenges, such as the lack of visualization inside the manikin and quantification of performance, resulting in inaccurate guidance and highly variable manual assessment. We present a Cross Reality (XR) ETI simulation system which registers ETI training tools to their virtual counterparts. Thus, our system can capture all aspects of motions and visualize the entire procedure, offering instructors with sufficient information for assessment. A machine learning approach was developed to automatically evaluate the ETI performance for standardizing assessment protocols by using the performance parameters extracted from the motions and the scores from an expert rater. The classification accuracy of the machine learning algorithm is 83.5%.

Development of an Endotracheal Intubation Formative Assessment Tool

Valid methods for providing detailed formative feedback on direct laryngoscopy and endotracheal intubation (ETI) performance do not exist. We are developing an observation-based assessment tool for measuring performance and providing feedback during ETI. Based on the literature and interviews of experts, we proposed an initial ETI metric with 22 items. Six anesthesiology experts used it to assess the quality of ETI performance in videotaped intubations. Following metric revisions, 2 expert groups assessed 2 collections of videos (27 total) using the revised metric. Two reference standards for comparison with metric scores were created with a third and fourth group of experts; (1) an average global rating (1-100) of each ETI performance and (2) average rank-ordered performance from best to worst. Rater agreement and correlations between the 2 methods were calculated. Regression analysis determined items that optimally discriminated quality. When calculating a score based on all clinically important terms, multiple weightings were evaluated. Metric items had high average rater agreement (80%) with intraclass correlation coefficients averaging 0.83. Correlations of the reference rank and score were high for both video collections (-0.96, P < .05, and -0.95, P < .05). Regression coefficients for different item weighting methods indicated strong relationships with global ratings (averaging r = 0.89, P < .05) and rankings averaging -0.85, P < .05). Prediction of global ratings using regression achieved high accuracy (R 2 = 0.8218). High observer agreement and strong correlations between metric and rank data support the validity of using this metric to assess ETI performance. Different weighting models yielded scores that correlated strongly with the ratings and ranks from global assessment. When using the metric to predict competency, a 3-item regression model is most accurate in predicting a global score.

How much experience do rescuers require to achieve successful tracheal intubation during cardiopulmonary resuscitation?

AimThe cardiopulmonary resuscitation (CPR) guidelines recommend that endotracheal intubation (ETI) should be performed only by highly skilled rescuers. However, the definition of ‘highly skilled’ is unclear. This study evaluated how much experience with ETI is required for rescuers to perform successful ETI quickly without complications including serious chest compression interruption (interruption time <10 s) or oesophageal intubation during CPR. MethodsThis was a clinical observation study using review of CPR video clips in an urban emergency department (ED) over 2 years. Accumulated ETI experience and performance of ETI were analysed. Main outcomes were 1) ‘qualified ETI’: successful ETI within 60 s without complications and 2) ‘highly qualified ETI’: successful ETI within 30 s without complications. ResultsWe analysed 110 ETIs using direct laryngoscopy during CPR. The success rate improved and the time to successful ETI decreased with increasing experience; however, the total interruption time of chest compression did not decrease. A 90% success rate for qualified ETI required 137 experiences of ETIs (1218 days of training). A 90% success rate for highly qualified ETI required at least 243 experiences of ETIs (1973 days of training). ConclusionsAccumulated experience can improve the ETI success rate and time to successful ETI during CPR. Because ETI must be performed quickly without serious interruption of chest compression during CPR, becoming proficient at ETI requires more experience than that required for non-arrest patients. In our analysis, more than 240 experiences were required to achieve a 90% success rate of highly qualified ETI.

Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest

Emergency medical services (EMS) commonly perform endotracheal intubation (ETI) or insertion of supraglottic airways, such as the laryngeal tube (LT), on patients with out-of-hospital cardiac arrest (OHCA). The optimal method for OHCA advanced airway management is unknown. To compare the effectiveness of a strategy of initial LT insertion vs initial ETI in adults with OHCA. Multicenter pragmatic cluster-crossover clinical trial involving EMS agencies from the Resuscitation Outcomes Consortium. The trial included 3004 adults with OHCA and anticipated need for advanced airway management who were enrolled from December 1, 2015, to November 4, 2017. The final date of follow-up was November 10, 2017. Twenty-seven EMS agencies were randomized in 13 clusters to initial airway management strategy with LT (n = 1505 patients) or ETI (n = 1499 patients), with crossover to the alternate strategy at 3- to 5-month intervals. The primary outcome was 72-hour survival. Secondary outcomes included return of spontaneous circulation, survival to hospital discharge, favorable neurological status at hospital discharge (Modified Rankin Scale score ≤3), and key adverse events. Among 3004 enrolled patients (median [interquartile range] age, 64 [53-76] years, 1829 [60.9%] men), 3000 were included in the primary analysis. Rates of initial airway success were 90.3% with LT and 51.6% with ETI. Seventy-two hour survival was 18.3% in the LT group vs 15.4% in the ETI group (adjusted difference, 2.9% [95% CI, 0.2%-5.6%]; P = .04). Secondary outcomes in the LT group vs ETI group were return of spontaneous circulation (27.9% vs 24.3%; adjusted difference, 3.6% [95% CI, 0.3%-6.8%]; P = .03); hospital survival (10.8% vs 8.1%; adjusted difference, 2.7% [95% CI, 0.6%-4.8%]; P = .01); and favorable neurological status at discharge (7.1% vs 5.0%; adjusted difference, 2.1% [95% CI, 0.3%-3.8%]; P = .02). There were no significant differences in oropharyngeal or hypopharyngeal injury (0.2% vs 0.3%), airway swelling (1.1% vs 1.0%), or pneumonia or pneumonitis (26.1% vs 22.3%). Among adults with OHCA, a strategy of initial LT insertion was associated with significantly greater 72-hour survival compared with a strategy of initial ETI. These findings suggest that LT insertion may be considered as an initial airway management strategy in patients with OHCA, but limitations of the pragmatic design, practice setting, and ETI performance characteristics suggest that further research is warranted. ClinicalTrials.gov Identifier: NCT02419573.

Impact of stylet use in a simulated difficult airway model

BackgroundStylet use during endotracheal intubation (ETI) is variable across medical specialty and geographic location; however, few objective data exist regarding the impact of stylet use on ETI performance. ObjectiveWe evaluated the impact of stylet use on the time required to perform ETI in cases of simulated difficult airways in novice and experienced providers. MethodsWe performed a prospective, randomized observational study of experienced (attending anesthesiologists and emergency physicians) vs inexperienced airway providers (emergency medical technician, paramedic and medical students) comparing the use of stylet vs no stylet in random order using a simulated difficult airway. The primary outcome was attempt time for each of 6 attempts defined as entry of the laryngoscope in the mouth until successfully passing the endotracheal tube past the vocal cords. We analyzed the data using descriptive statistics including means with SDs and t tests. We used generalized estimating equations to evaluate potential changes in the attempt time over multiple attempts. ResultsThere were 23 providers per group. The mean (SD) inexperienced attempt time in seconds was 25.88 (28.46) and 10.50 (5.47) for experienced providers (P < .0001). Stylet use did not alter attempt time for either group. When adjusting for stylet use, the attempt time did not change over repeated intubations (P = .541). When adjusting for experience status, inexperienced intubators had shorter attempt times with each successive trial, whereas experienced intubators attempt times remained constant (P < .001). ConclusionStylet use does not improve attempt time in a simulated difficult airway model for either inexperienced or experienced intubators.

Variables Associated with Successful Intubation Attempts Using Video Laryngoscopy: A Preliminary Report in a Helicopter Emergency Medical Service

Background. Multiple studies have demonstrated varying rates of successful endotracheal intubation (ETI). Until the application of video laryngoscopy, little information regarding prehospital intubation could be analyzed objectively by individuals other than the provider performing the ETI. Objective. To evaluate the association of variables recorded during video laryngoscopy and successful ETI attempts, defined as placing the endotracheal tube in the trachea. Methods. We retrospectively reviewed intubations performed by a single helicopter emergency medical service (HEMS) using a video larygoscope from March 1, 2010, to October 1, 2010. All videos were de-identified and analyzed by a single researcher. Time intervals (e.g., attempt time) and intubation process variables (e.g., Cormack-Lehane [C-L] view) were abstracted from all videos. Time intervals were begun when the laryngoscope blade passed the lips and entered the oral cavity (entry). We describe variables using means and standard deviations (continuous), medians with interquartile ranges (ordinal), and percentages with 95% confidence intervals (categorical). We then looked at univariate associations between these variables and ETI success using logistic regression. Results. We recorded 116 intubations during the study period. Twenty-nine recordings were either incomplete (n = 26) or of insufficient quality for analysis (n = 3). The remaining 87 videos represented 87 different patients with a total of 102 attempts at laryngoscopy. Thirty-six providers performed 64 cases, with the majority of providers (n = 21) performing only one intubation. The first-pass success rate in this series was 76% (n = 66), with 98% success within three attempts. Successful ETI attempts had lower entry–to–percentage of glottic opening (POGO) times (16.6 sec vs. 32.1 sec, p = 0.013), entry–to–first view of the endotracheal tube or entry-to-tube times (17.6 sec vs. 27.4 sec, p = 0.04), higher POGO scores (76 vs. 39, p < 0.001), and a lower C-L view (one vs. three, p < 0.001). Recognized esophageal intubation was more likely to occur during unsuccessful ETI attempts (43% vs. 8%, p < 0.001). Conclusion. Video laryngoscopy can measure multiple components of ETI performance. Successful ETI attempts have significantly shorter entry-to-POGO times and entry-to-tube times, obtain better views of the glottic opening (POGO and C-L view), and have a lower incidence of recognized esophageal intubation.

Expertise in prehospital endotracheal intubation by emergency medicine physicians—Comparing ‘proficient performers’ and ‘experts’

BackgroundTraining requirements to perform safe prehospital endotracheal intubation (ETI) are not clearly known. This study aimed to determine differences in ETI performance between ‘proficient performers’ and ‘experts’ according to the Dreyfus & Dreyfus framework of expertise. As a model for ‘proficient performers’ EMS physicians with a clinical background in internal medicine were compared to EMS physicians with a background in anaesthesiology as a model for ‘experts’. MethodsOver a one-year period all ETIs performed by the EMS physicians of our institution were prospectively evaluated. ‘Proficient performers’ and ‘experts’ were compared regarding incidence of difficult ETI, ability to predict difficult ETI, and decision for ETI. ResultsMean years of professional experience were similar between the physician groups, but the median ETI experience differed significantly with 18/year for ‘proficients’ and 304/year for ‘experts’ (p<0.001). ‘Proficient performers’ intubated 130 of their 2170 treated patients (6.0%), while ‘experts’ did so in 146 of 1809 cases (8.1%, p=0.01 for difference). The incidence of difficult ETI was 17.7% for ‘proficient performers’, and 8.9% for ‘experts’ (p<0.05). In 4 cases ETI was impossible, all managed by ‘proficient performers’, but all patients could be ventilated sufficiently. Unexpected difficult ETI occurred in 6.1% for ‘proficient performers’, and 2.0% for ‘experts’ (p=0.08). ConclusionsIn a prehospital setting ‘expert’ status was associated with a significantly lower incidence of ‘difficult ETI’ and a higher proportion of ETI decisions. In addition, ability to predict difficult ETI was higher, although non-significant. There was no difference in the incidence of impossible ventilation.

Paramedic Perceptions of Challenges in Out-of-Hospital Endotracheal Intubation

Objective. Paramedics often perform endotracheal intubation (ETI), insertion of a breathing tube, on critically ill out-of-hospital patients. Recent studies highlight important paramedic ETI shortcomings including adverse events, errors, andpoor outcomes resulting from this procedure. Little is known about workforce perceptions of these events. We sought to identify paramedic andphysician perceptions regarding the challenges andpitfalls of out-of-hospital ETI. Methods. We conducted a qualitative study involving paramedic focus groups sessions andindividual interviews with Emergency Medical Services (EMS) physician medical directors. We recorded andtranscribed all sessions. We used inductive theory construction to examine, organize, andclassify thematic patterns. Results. Fourteen paramedics and6 physicians participated. Although paramedics andphysicians recognized problems with paramedic ETI, all participants strongly felt that paramedics should continue to perform the procedure. Physicians andparamedics disagreed about the ability of paramedics to perform neuromuscular blockade-assisted intubation. Both groups identified aspects of paramedic education, skills acquisition, andmaintenance as core issues. Participants also identified broader factors about the structure of emergency services, the role of the medical director, andworkforce culture andprofessionalism. Conclusion. Paramedics andEMS physicians attribute paramedic ETI performance to a myriad of factors involving EMS education, organization, oversight, retention, andprofessionalism. Efforts to improve ETI must include strategies to address multiple aspects of EMS operations andculture.

P ATIENT S TATUS AND T IME TO I NTUBATION IN THE A SSESSMENT OF P REHOSPITAL I NTUBATION P ERFORMANCE

Assessment of paramedic endotracheal intubation (ETI) performance often does not account for varied clinical conditions or the time required to complete the procedure. Objective. To demonstrate the utility of patient status and time to intubation (TTI) for evaluating prehospital ETI performance. Methods. Paramedic charts were reviewed for the period January-December 1998. Patient clinical status was defined as cardiac arrest (absence of perfusing rhythm) or non-cardiac arrest (presence of perfusing rhythm). Method, route, and success of ETI were noted. The TTI was determined as the elapsed time from on-scene arrival to securing of the endotracheal tube. Time elapsed from on-scene arrival to emergency department arrival was noted for instances of failed ETI. Statistical analysis was performed using chi-square and survival analysis (Kaplan-Meier estimator). Results. Computer records were available for 26,026 patient contacts. Of 893 documented ETI attempts, 771 (86%) were successful. The ETI success rate was significantly higher (p < 0.001) for cardiac arrests (551 of 591, 93.2%) than for non-cardiac arrests (220 of 302, 72.9%). Median TTIs were 5 minutes (95% CI: 5, 5) for cardiac arrests and 17 minutes (95% CI: 14, 20) for non-cardiac arrests; this difference was significant (p < 0.001). For non-cardiac arrests, ETI success was significantly (p = 0.002) higher for orotracheal intubation (OTI) (168 of 214, 78.5%) than for nasotracheal intubation (NTI) (52 of 88, 59.1%). Median TTIs were 15 minutes (95% CI: 13, 17) for OTI and 25 minutes (95% CI: 23, 27) for NTI; this difference was significant (p = 0.002). For non-cardiac arrests, the difference in ETI success rates between conventional ETI (63 of 88, 71.6%) and midazolam-facilitated ETI (157 of 214, 73.4%) was not significant (p = 0.75). Median TTIs were 16 minutes (95% CI: 13, 19) for conventional ETI and 19 minutes (95% CI: 16, 22) for the midazolam-facilitated ETI; this difference was not significant (p = 0.08). Conclusions. The TTI is shorter and ETI success rates are higher for patients in cardiac arrest. Similar trends are observed for OTI compared with NTI in non-cardiac arrest patients. Success rates and TTIs for conventional vs midazolam-facilitated intubation in non-cardiac arrest patients do not differ. Prehospital ETI data should be segregated according to patient clinical status. Survival analysis of TTI can be used to establish time benchmarks for performing field intubation and to define strategies for approaching field intubation.

The impact of a didactic session on the success of feline endotracheal intubation by paramedics

Clinical reports of endotracheal (ET) intubation of infants by paramedics suggest suboptimal success rates. Methods to improve the performance of paramedics in ET intubation should be explored. The small, anesthetized cat may be utilized to evaluate infant ET intubation performance. By determining success rates and complications of ET intubation in the cat model, analysis of the current skills and the impact of a short didactic session is described. Unprepared paramedics (n = 36) were randomized to an educational (experimental) or control group. Supervisory personnel evaluated ET tube placement and complications. There was no significant difference in the percent of successfully intubated cats, 67% and 57%, respectively, between experimental and control groups. Fifteen percent of successful ET intubations exceeded 30 seconds of intubation time. The experimental group chose appropriate equipment more frequently. Serious complications occurred in 50% of attempted intubations. There was a poor correlation between performance and measures of paramedic experience. Development of educational methods is required to improve infant ET intubation success and reduce complications.

The impact of a didactic session on the success of feline endotracheal intubation by paramedics

Clinical reports of endotracheal (ET) intubation of infants by paramedics suggest suboptimal success rates. Methods to improve the performance of paramedics in ET intubation should be explored. The small, anesthetized cat may be utilized to evaluate infant ET intubation performance. By determining success rates and complications of ET intubation in the cat model, analysis of the current skills and the impact of a short didactic session is described. Unprepared paramedics (n = 36) were randomized to an educational (experimental) or control group. Supervisory personnel evaluated ET tube placement and complications. There was no significant difference in the percent of successfully intubated cats, 67% and 57%, respectively, between experimental and control groups. Fifteen percent of successful ET intubations exceeded 30 seconds of intubation time. The experimental group chose appropriate equipment more frequently. Serious complications occurred in 50% of attempted intubations. There was a poor correlation between performance and measures of paramedic experience. Development of educational methods is required to improve infant ET intubation success and reduce complications.