Intubation Training Research Articles

Efficacy of double-lumen intubation performed by paramedics on patients with lung damage. Experimental, pilot simulation trial

INTRODUCTION: The airway management and the implementation of optimal oxygen therapy in trauma patients, especially unconscious ones, is a key element of prehospital management. However, in cases of trauma lung or bronchial rupture, both lungs ventilation may not be advisable. In such cases, intubation with a double-lumen endotracheal tube may be helpful, allowing to provide one-lung ventilation. The aim of the experimental study was to assess the impact of short training in intubation using double-lumen tubes on the effectiveness of intubation performance and one-lung ventilation by paramedics in a simulated trauma patient setting. MATERIAL AND METHODS: This was a prospective, observational, randomized experimental trial. The study involved 30 paramedics. The participants had to perform tracheal intubation using Double Lumen Tube VivaSight-DL (VS-DL; ETView Ltd.; Misgav, Israel) under normal airway conditions. The effectiveness of the first intubation attempt, the time of intubation and the Cormack-Lehane scale were evaluated. RESULTS: The effectiveness of the first attempt at intubation with a double-lumen tube was 90% and the total effectiveness of intubation was 100%. The median time of the procedure was 63 (IQR; 38–72.5) seconds. CONCLUSIONS: In the simulation study, the paramedics were able to intubate using a double tube after a short 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%.

The experiences of EMS providers taking part in a large randomised trial of airway management during out of hospital cardiac arrest, and the impact on their views and practice. Results of a survey and telephone interviews

AimsTo explore EMS experiences of participating in a large trial of airway management during out-of-hospital cardiac arrest (AIRWAYS-2), specifically to explore:1. Any changes in views and practice as a result of trial participation.2. Experiences of trial training.3. Experiences of enrolling critically unwell patients without consent.4. Barriers and facilitators for out-of-hospital trial participation. MethodsAn online questionnaire was distributed to 1523 EMS providers who participated in the trial. In-depth telephone interviews explored the responses to the online questionnaire.Quantitative data were collated and presented using simple descriptive statistics. Qualitative data collected during the online survey were analysed using content analysis. Interpretive Phenomenological Analysis was used for qualitative interview data. ResultsResponses to the online questionnaire were received from 33% of the EMS providers who participated in AIRWAYS-2, and 19 providers were interviewed. EMS providers described barriers and facilitators to trial participation and changes in their views and practice.The results are presented in five distinct themes: research process; changes in airway management views and practice; engagement with research; professional identity; professional competence. ConclusionsParticipation in the AIRWAYS-2 trial was enjoyable and EMS providers valued the study training and support. There was enhanced confidence in airway management as a result of taking part in the trial. EMS providers indicated existing variability in training, experience and confidence in tracheal intubation, and expressed a preference for the method of airway management to which they had been randomised. There was support for the stepwise approach to airway management, but also concern regarding the potential loss of tracheal intubation from ‘standard’ EMS practice. The views and practices of the EMS providers expressed in this research will usefully inform the design of future similar trials.

A DAS members survey of education and training in awake tracheal intubation

A DAS members survey of education and training in awake tracheal intubation

Improving fibreoptic intubation assessments and training

Improving fibreoptic intubation assessments and training

The application of UE videolaryngoscope in tracheal intubation training by novice non-anesthesia residents

The application of UE videolaryngoscope in tracheal intubation training by novice non-anesthesia residents

Simulating a bleeding airway model for intubation training

Simulating a bleeding airway model for intubation training

Nationwide survey on training and device utilization during tracheal intubation in French intensive care units

BackgroundIntubation is a lifesaving procedure that is often performed in intensive care unit (ICU) patients, but leads to serious adverse events in 20–40% of cases. Recent trials aimed to provide guidance about which medications, devices, and modalities maximize patient safety. Videolaryngoscopes are being offered in an increasing range of options and used in broadening indications (from difficult to unremarkable intubation). The objective of this study was to describe intubation practices and device availability in French ICUs.Materials and methodsWe conducted an online nationwide survey by emailing an anonymous 26-item questionnaire to physicians in French ICUs. A single questionnaire was sent to either the head or the intubation expert at each ICU.ResultsOf 257 ICUs, 180 (70%) returned the completed questionnaire. The results showed that 43% of intubators were not fully proficient in intubation; among them, 18.8% had no intubation training or had received only basic training (lectures and observation at the bedside). Among the participating ICUs, 94.4% had a difficult intubation trolley, 74.5% an intubation protocol, 92.2% a capnography device (used routinely to check tube position in 69.3% of ICUs having the device), 91.6% a laryngeal mask, 97.2% front-of-neck access capabilities, and 76.6% a videolaryngoscope. In case of difficult intubation, 85.6% of ICUs used a bougie (154/180) and 7.8% switched to a videolaryngoscope (14/180). Use of a videolaryngoscope was reserved for difficult intubation in 84% of ICUs (154/180). Having a videolaryngoscope was significantly associated with having an intubation protocol (P = 0.043) and using capnography (P = 0.02). Airtraq® was the most often used videolaryngoscope (39.3%), followed by McGrath®Mac (36.9%) then by Glidescope® (14.5%).ConclusionNearly half the intubators in French ICUs are not fully proficient with OTI. Access to modern training methods such as simulation is inadequate. Most ICUs own a videolaryngoscope, but reserve it for difficult intubations.

Endotracheal intubation training to medical practitioners: Comparison of the modified 4-step Payton's training method and Halsted's training method in a simulated environment

INTRODUCTION:The ability of physicians to perform endotracheal intubation by laryngoscope is one of the essential skills. The purpose of this study was to evaluate the effectiveness of the four-step python training method with the Halsted's “See one, Do one, and Teach one” training method in endotracheal intubation competency in simulated environment.MATERIALS AND METHODS:This quasi-experimental study was performed on two independent groups with posttest. The statistical society consisted of eighth-semester medical students referred to the emergency medicine unit. The experimental group received a modified four-step python's training method that modified for small groups, and the control group received the Halsted's “See one, Do one, and Teach one” training method. Researcher-made checklist used to rate participant competency as posttest. Data were analyzed using SPSS 19 software.RESULTS:Sixty-seven students volunteered for the experimental group and 57 students for the control group. In posttest, the experimental group more competent than the control group significantly (P < 0.001). Furthermore, the training course satisfaction of the experimental group was significantly higher than the control group (P < 0.001).DISCUSSION AND CONCLUSION:Modified python training method for small groups has shown a better effect on student performance. This finding is consistent with previous researches. Modified four-step python's training for small group with an emphasis on peer to peer teaching and receiving feedback from peer can be related to the effectiveness of this training. Further research is recommended in other clinical education settings.

Pecha Kucha with Part-Task Training Improves Airway Management in Fresh Frozen Cadavers: A Case-Control Observational Study

Objective: The objective of this study was to ascertain whether the addition of part-task training as a step in Pecha Kucha for fiberoptic tracheal intubation increases the success rate and reduces the complication rate. Subjects and Methods: The residents of the Department of Anesthesiology were initially included in an orientation program. We used the Pecha Kucha method for the presentation of teaching fiberoptic intubation skills. Afterwards the participants were trained in Laerdal® airway management and each participant performed tracheal intubation using the Aintree catheter. The participants were divided into two groups. Group 1 (n = 9) received part-task training and group 2 (n = 9) received whole-task training. The tracheal intubation performances of participants were evaluated on fresh frozen cadavers. The number of interventions, incidence of complications, success rate, and optimization maneuver requirements were recorded. Results: Eighteen residents aged between 27 and 33 years were included. All were junior residents with less than 2 years of experience. There was no significant difference in terms of duration of tracheal intubation, complication rates, and optimization maneuvers between the study groups. Six participants could not place the tracheal tube in the last section. The success rates for the part-task group during Aintree and tracheal tube placement were 100 and 66.7%, respectively, whereas the rates were 55.6 and 44.4%, respectively, in whole-task group (p < 0.05). Conclusion: In addition to the Pecha Kucha method in fiberoptic intubation training, simulation-based part-task training appears to increase the success rate and to reduce the complication rate on fresh frozen cadavers.

Comparing Simulators Used in Fiber-optic Intubation Training Among Anesthesia Residents

Comparing Simulators Used in Fiber-optic Intubation Training Among Anesthesia Residents

Multiple intubation attempts in the emergency department and in-hospital mortality: A retrospective observational study

ObjectivesMultiple intubation attempts in the Emergency Department (ED) have been associated with adverse events, but no study examined the influence of multiple intubation attempts on survival during hospitalization. Our aim was to compare one or more intubation attempts in the ED with risk of morbidity and mortality during hospitalization. MethodsWe conducted a single center retrospective analysis of all patients undergoing emergency intubation in the ED and then admission to the hospital, during September 2010 to April 2016. The primary exposure was multiple intubation attempts. The primary outcome was mortality during hospitalization after intubation in the ED. ResultsOf 181 patients, 63 (35%) required two or more attempts. We found no significant difference in mortality (p = 0.11), discharge from the hospital (p = 0.45), length of stay in hospital (p = 0.34), intensive care unit (ICU) (p = 0.32), ED (p = 0.81) or intubation period (p = 0.64), between one or more intubation attempts. After adjustment for the number of intubation trials, age, sex, intubation methods, first intubator training level and diagnostic category, use of medications during intubation was the only independent prognostic variable for hospital death (adjusted OR 0.21, 95%CI 0.1–0.45, p < 0.01). Number of trials to achieve successful intubation was not associated with discharge disposition (OR 0.77 95%CI 0.24–2.46, p = 0.66). Age (OR 0.95, 95%CI 0.93–0.98, p < 0.01) and brain injury as a diagnostic category (OR 0.15 95%CI 0.04–0.56, p < 0.01) were independent prognostic variables. ConclusionsWe found multiple intubation attempts were not associated with increased mortality and morbidity during hospitalization.

Case report of neonate Pierre Robin sequence with severe upper airway obstruction who was rescued by finger guide intubation

BackgroundPierre Robin Sequence (PRS) patients are known for their triad of micrognathia, glossoptosis, and airway obstruction. Their airway can be a challenge even for the most experienced pediatric anesthesiologist.Case presentationWe report the case of a 9 day old 3.5 kg boy diagnosed with PRS, cleft palate, and a vallecular cyst with severe upper airway obstruction. The combination of PRS, cleft palate and the presence of vallecular cyst made this a cascade reaction of difficult airway. Due to his unique anatomy, we didn’t appreciate how difficult his airway was until multiple attempts with high-tech equipment failed. Ultimately it was the finger guide intubation, this old technique without any equipment, that rescued this patient from lose of airway.ConclusionsThe boy was successfully rescued by finger guided intubation. Finger guide intubation should be added to the anesthesiologist’s newborn rescue intubation training.

Royal Perth Hospital airway &amp; head and neck anesthesiology fellowship

Royal Perth Hospital airway &amp; head and neck anesthesiology fellowship

Development of Classification Models for Assessment of Endotracheal Intubation Training by a Cyber-Physical System

Endotracheal intubation (ETI) is one of the most staple skills in prehospital medicine that is performed to prevent suffocation of an unconscious person. To evaluate ETI skills of medical practitioners, an effective and reliable assessment system is required; however, the current assessment method relies on subjective evaluation by supervisors during training sessions that may be inaccurate and biased. To provide objective and immediate feedback to trainees, this paper proposes a cyber physical system (CPS)-based ETI assessment system. The CPS is composed of wearable gloves with embedded sensors to capture hand motion data and software to discriminate between two groups: experienced and novice. To this end, we collected hand motion data from the two groups and extracted 18 features. Furthermore, we identified reduced sets of 8 and 10 based on their statistical significance. To discriminate the two groups, artificial neural network-based classification models were developed with the three feature sets. Experimental results show that the classifiers with 18, 8, and 10 features achieved an accuracy of 90.94%, 87.87% and 89.60%, respectively. This work corroborates that wearable gloves with embedded motion sensors can be effective in assisting self-training of ETI on a CPS.

Impact of a custom-made 3D printed ergonomic grip for direct laryngoscopy on novice intubation performance in a simulated easy and difficult airway scenario-A manikin study.

Direct laryngoscopy using a Macintosh laryngoscope is the most widely used approach; however, this skill is not easy for novices and trainees. We evaluated the performance of novices using a laryngoscope with a three-dimensional (3D)-printed ergonomic grip on an airway manikin. Forty second-year medical students were enrolled. Endotracheal intubation was attempted using a conventional Macintosh laryngoscope with or without a 3D-printed ergonomic support grip. Primary outcomes were intubation time and overall success rate. Secondary outcomes were number of unsuccessful attempts, first-attempt success rate, airway Cormack-Lehane (CL) grade, and difficulty score. In the easy airway scenario, intubation time, and the overall success rate were similar between two group. CL grade and ease-of-use scores were significantly better for those using the ergonomic support grip (P < 0.05). In the difficult airway scenario, intubation time (49.7±37.5 vs. 35.5±29.2, P = 0.013), the first-attempt success rate (67.5% vs. 90%, P = 0.029), number of attempts (1.4±0.6 vs. 1.1±0.4, P = 0.006), CL grade (2 [2, 2] vs. 2 [1, 1], P = 0.012), and ease-of-use scores (3.5 [2, 4] vs. 4 [3, 5], P = 0.008) were significantly better for those using the ergonomic support grip. Linear mixed model analysis showed that the ergonomic support grip had a favorable effect on CL grade (P<0.001), ease-of-use scores (P<0.001), intubation time (P = 0.015), and number of intubation attempts (P = 0.029). Our custom 3D-printed ergonomic laryngoscope support grip improved several indicators related to the successful endotracheal intubation in the easy and difficult scenario simulated on an airway manikin. This grip may be useful for intubation training and practice.

Adherence to the neonatal resuscitation algorithm for preterm infants in a tertiary hospital in Spain

BackgroundThere is evidence that delivery room resuscitation of very preterm infants often deviates from internationally recommended guidelines. There were no published data in Spain regarding the quality of neonatal resuscitation. Therefore, we decided to evaluate resuscitation team adherence to neonatal resuscitation guidelines after birth in very preterm infants.MethodsWe conducted an observational study. We video recorded resuscitations of preterm infants < 32 weeks’ gestational age and evaluated every step during resuscitation according to a score-sheet specifically designed for this purpose, following Carbine’s method, where higher scores indicated that more intense resuscitation maneuvers were required. We divided the score achieved by the total possible points per patient to obtain the percentage of adherence to the algorithm. We also compared resuscitations performed by staff neonatologists to those performed by pediatricians on-call. We compared percentages of adherence to the algorithm with the Chi-square test for large groups and Fisher’s exact test for smaller groups. We compared assigned Apgar scores with those given after analyzing the recordings and described them by their median and interquartile range. We measured the interrater agreement between Apgar scores with Cohen’s kappa coefficient. Linear and logarithmic regressions were drawn to characterize the pattern of algorithm adherence. Statistical analysis was performed using SPSS V.20. A p-value < 0.05 was considered significant. Our Hospital Ethics Committee approved this project, and we obtained parental written consent beforehand.ResultsSixteen percent of our resuscitations followed the algorithm. The number of mistakes per resuscitation was low. Global adherence to the algorithm was 80.9%. Ventilation and surfactant administration were performed best, whereas preparation and initial steps were done with worse adherence to the algorithm. Intubation required, on average, 2.2 attempts; success on the first attempt happened in 33.3% of cases. Only 12.5% of intubations were achieved within the allotted 30 s. Many errors were attributable to timing. Resuscitations led by pediatricians on-call were performed as correctly as those by staff neonatologists.ConclusionsResuscitation often deviates from the internationally recognized algorithm. Perfectly performed resuscitations are infrequent, although global adherence to the algorithm is high. Neonatologists and pediatricians need intubation training.

Paediatric airway management and concerns: a survey of advanced paramedics in Ireland.

Paediatric airway management is of fundamental importance in the critically unwell child. Pre-hospital paediatric airway management especially endotracheal intubation is however controversial. To explore Irish Advanced Paramedics (APs) training, experience and clinical practice in paediatric airway management as well as to examine clinician attitudes toward this topic. An anonymous online survey of all graduates of the University College Dublin AP training program (N = 453). With duplicates and failed email deliveries excluded a valid sample of 382 individuals was obtained from whom a response rate of 185/382 (48.4%) was achieved. Three quarters of responding APs worked in urban or mixed practice with the remaining minority operating primarily in rural areas. One quarter of responding APs reported formal training in paediatric intubation. Almost 70% of APs had encountered a child requiring significant airway management in the preceding year. However, this was a rare exposure in terms of overall workload. Basic airway adjuncts were used frequently in such circumstances, with endotracheal intubation having been attempted by only a small minority of APs. Lack of practice was identified by many responding APs as a key issue causing concern in terms of paediatric intubation. Paediatric airway management has key relevance for pre-hospital care in Ireland. The overall frequency of exposure to children who may benefit from definitive airway management is however likely to represent a significant barrier to the acquisition and maintenance of competency. The ongoing practice of pre-hospital paediatric intubation by APs may not justify its risks.

O papel do videolaringoscópio em programas de treinamento de intubação endotraqueal

BackgroundMacintosh laryngoscopes are widely used for endotracheal intubation training of medical students and paramedics whereas there are studies in the literature that supports videolaryngoscopes are superior in endotracheal intubation training. Our aim is to compare the endotracheal intubation time and success rates of videolaryngoscopes and Macintosh laryngoscopes during endotracheal intubation training and to determine the endotracheal intubation performance of the students when they have to use an endotracheal intubation device other than they have used during their education. MethodsEndotracheal intubation was performed on a human manikin owing a standard respiratory tract by Macintosh laryngoscopes and C-MAC® videolaryngoscope (Karl Storz, Tuttligen, Germany). Eighty paramedic students were randomly allocated to four groups. At the first week of the study 10 endotracheal intubation trials were performed where, Group‐MM and Group‐MV used Macintosh laryngoscopes; Group‐VV and Group‐VM used videolaryngoscopes. Four weeks later all groups performed another 10 endotracheal intubation trial where Macintosh laryngoscopes was used in Group‐MM and Group‐VM and videolaryngoscopes used in Group‐VV and Group‐MV. ResultsSuccess rates increased in the last 10 endotracheal intubation attempt in groups MM, VV and MV (p=0.011; p=0.021, p=0.290 respectively) whereas a decrease was observed in group‐VM (p=0.008). ConclusionsThe success rate of endotracheal intubation decreases in paramedic students who used VL during endotracheal intubation education and had to use Macintosh laryngoscopes later. Therefore we believe that solely videolaryngoscopes is not enough in endotracheal intubation training programs.

C-MAC© videolaryngoscopy: The anaesthetic assistant's view.

Although videolaryngoscopy plays a major role in the 2015 Difficult Airway Society guidelines, the impact on anaesthetic assistant working practices and training has not previously been reported. We surveyed anaesthetic assistants in our hospital to document their experience with using the C-MAC© videolaryngoscope (48 practitioners, 100% response rate). Improvements in the following were reported: patient safety 100%; ability to see whether laryngoscopy is difficult 98%; ability to anticipate the 'next step' 98%; team-working and human factors 96%; ability to call a senior anaesthetist more quickly 94%; assessment or adjustment of cricoid force application 92%, understanding of laryngeal anatomy 92%; training in intubation 98%; training in cricoid force application 87%. Concerns were primarily about local issues such as decontamination and blade availability. Ninety percent reported that the clinical benefit outweighed any additional workload. In conclusion, the C-MAC© videolaryngoscope is judged by anaesthetic assistants to confer numerous advantages for their working practice and training.