Endotracheal Intubation Training Research Articles

Postmortem intubation training: patient and family opinion

Endotracheal intubation is a life-saving skill which requires training to master. Learning opportunities for endotracheal intubation must be balanced with patient rights and intentions. This study was conducted to explore patient and family opinions about postmortem endotracheal intubation training. We carried out an observational, cross-sectional survey study in an urban, teaching hospital, on the day of hospital discharge. Subjects were neurologically unimpaired neurosurgical patients discharged from hospital in 2004-2005, and their relatives. We carried out interviews using a standardised script to determine whether subjects would permit postmortem intubation training on themselves or relatives, and whether permission should be granted by relatives before training. A total of 85% of patient and family respondents would allow intubation training after death on themselves, 76% would allow endotracheal intubation to be practised on a relative, and 81% felt the deceased's next-of-kin should be asked for permission prior to endotracheal intubation training. Subjects responded consistently as to what they would allow on self and family. Knowledge that the deceased person would have agreed to his or her body being used in endotracheal intubation training increased their likelihood of granting permission for training (P = 0.008). White subjects were 4.6 times more likely than non-Whites to allow intubation training on themselves (P = 0.01). Patients and families are agreeable to postmortem intubation training; however, most expect to be asked for permission. Utilising existing mechanisms which communicate desired treatment, such as advance directives, hospital admissions documents, donor registries or community health fairs may facilitate training opportunities and altruistic patient intentions.

Limited Opportunities for Paramedic Student Endotracheal Intubation Training in the Operating Room

Paramedics, who often are the first to provide emergency care to critically ill patients, must be proficient in endotracheal intubation (ETI). Training in the controlled operating room (OR) setting is a common method for learning basic ETI technique. To determine the quantity and nature of OR ETI training currently provided to paramedic students. The authors surveyed directors of paramedic training programs accredited by the Commission on Accreditation of Allied Health Education Programs. An anonymous 12-question, structured, closed-response survey instrument was used that requested information regarding the duration and nature of OR training provided to paramedic students. The results were analyzed by using descriptive statistics. From 192 programs, 161 completed surveys were received (response rate, 85%). OR training was used at 156 programs (97%) but generally was limited (median, 17-32 hours per student). Half of the programs provided fewer than 16 OR hours per student. Students attempted a limited number of OR ETI (median, 6-10 ETI). Most respondents (61%) reported competition from other health care students for OR ETI. Other identified hindering factors included the increasing OR use of laryngeal mask airways and physicians' medicolegal concerns. Respondents from 52 (33%) programs reported a recent reduction in OR access, and 56 (36%) programs expected future OR opportunities to decrease. Despite its key role in airway management education, the quantity and nature of OR ETI training that is available to paramedic students is limited in comparison to that available to other ETI providers.

Limited Opportunities for Paramedic Student Endotracheal Intubation Training in the Operating Room

Limited Opportunities for Paramedic Student Endotracheal Intubation Training in the Operating Room

Human Patient Simulation Is Effective for Teaching Paramedic Students Endotracheal Intubation

The primary purpose of this study was to determine whether the endotracheal intubation (ETI) success rate is different among paramedic students trained on a human patient simulator versus on human subjects in the operating room (OR). Paramedic students (n = 36) with no prior ETI training received identical didactic and mannequin teaching. After randomization, students were trained for ten hours on a patient simulator (SIM) or with 15 intubations on human subjects in the OR. All students then underwent a formalized test of 15 intubations in the OR. The primary outcome was the rate of successful intubation. Secondary outcomes were the success rate at first attempt and the complication rate. The study was powered to detect a 10% difference for the overall success rate (alpha = 0.05, beta = 0.20). The overall intubation success rate was 87.8% in the SIM group and 84.8% in the OR group (difference of 3.0% [95% confidence interval {CI} = -4.2% to 10.1%; p = 0.42]). The success rate on the first attempt was 84.4% in the SIM group and 80.0% in the OR group (difference of 4.4% [95% CI = -3.4% to 12.3%; p = 0.27]). The complication rate was 6.3% in the SIM group and 4.4% in the OR group (difference of 1.9% [95% CI = -2.9% to 6.6%; p = 0.44]). When tested in the OR, paramedic students who were trained in ETI on a simulator are as effective as students who trained on human subjects. The results support using simulators to teach ETI.

Defining the Learning Curve for Paramedic Student Endotracheal Intubation

Background. Proficiency in endotracheal intubation (ETI) is assumed to improve primarily with accumulated experience on live patients. While the National Standard Paramedic Curriculum recommends that paramedic students (PSs) perform at least five live ETIs, these training opportunities are limited. Objective. To evaluate the effects of cumulative live ETI experience, elapsed duration of training, andclinical setting on PS ETI proficiency. Methods. The authors used longitudinal, multicenter data from 60 paramedic training programs over a two-year period. The PSs reported outcomes (success/failure) for all live ETIs attempted in the operating room (OR), the emergency department (ED), the intensive care unit (ICU), andother hospital or prehospital settings. Fixed-effects logistic regression was used to model up to 30 consecutive ETI efforts by each PS, accounting for per-PS clustering. For each patient, the authors evaluated the association between ETI success andthe PS's cumulative number of ETIs, adjusted for clinical setting, elapsed number of days from the first ETI encounter, andthe interaction (cumulative ETIs × elapsed days). Predicted probability plots were constructed depicting the “learning curve” overall andfor each clinical setting. Results. Between one and74 ETIs (median 7; IQR 4–12) were performed by each of 802 PSs. Of 7,635 ETIs, 6,464 (87.4%) were successful. Stratified by clinical setting, 6,311 (82.7%) ETIs were performed in the OR, 271 (3.6%) in the ED, 64 (0.8%) in the ICU, 86 (1.1%) in other in-hospital settings, and903 (11.8%) in the prehospital setting. For the 7,398 ETIs included in the multivariate analysis, cumulative number of ETI was associated with increased adjusted odds of ETI success (odds ratio 1.067 per ETI; 95% CI: 1.044–1.091). ETI learning curves were steepest for the ICU andprehospital settings but lower than for other clinical settings. Conclusions. Paramedic student ETI success improves with accumulated live experience but appears to vary across different clinical settings. Strategies for PS airway education must consider the volume of live ETIs as well as the clinical settings used for ETI training. Key words: intubation; intratracheal; emergency medical services; learning; allied health personnel.

Utilization of virtual reality for endotracheal intubation training.

Tracheal intubation is performed for urgent airway control in injured patients. Current methods of training include working on cadavers and manikins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time, the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The haptic device along with the real-time performance of the simulator give it both visual and physical realism. The three-dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many endotracheal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.

Learning endotracheal intubation in a clinical skills learning center: a quantitative study.

This study aimed to develop statistical models describing the learning of endotracheal intubation (ETI). We collected data from 100 subjects undergoing ETI training with intubatable medical models and manikins (airway trainers). Trainees initially viewed a video about ETI and an instructor demonstrated the technique. Subjects then made up to 17 supervised trials. Each trial was scored as a success or failure; this score was the primary outcome used in analyses. Random effects and population-averaged logit models, and a learning model intended to quantify the relative contributions of failed and successful trials to the learning process, were fitted to the data. The logit models provided evidence of differences in difficulty between different airway trainers and differences in success rate related to previous ETI experience. Trainees became familiar with an airway trainer after multiple trials, as demonstrated by a 50% decrease in the odds of successful ETI when starting on a new trainer. The learning model indicated that a trainee learns about as much from 1 successful ETI as from 12 (95% confidence interval, 2-23) failed trials. The results demonstrate the feasibility of statistical modeling of the learning of ETI and provide insight into the learning process.

Teaching basic EMTs endotracheal intubation: can basic EMTs discriminate between endotracheal and esophageal intubation?

Advanced airway intervention techniques are being considered for use by basic emergency medical technicians (EMTs). It was hypothesized that basic EMTs would be able to discriminate reliably between intratracheal and esophageal endotracheal tube placement in a mannequin model. An airway mannequin with a closed chest cavity was intubated randomly either esophageally or tracheally, and the cuff was inflated. A stethoscope, bag ventilator, and laryngoscope were available next to the mannequin. Placement was assessed by auscultation or direct visualization at the discretion of the EMT. A blinded investigator graded the student. A classroom in a large, urban medical center. Subjects were basic EMTs who volunteered to take part after the conclusion of a six-hour endotracheal intubation training course. Thirty-three subjects were tested. Seventeen of 18 (94%) tracheal intubations and 11 of 15 (73%) esophageal intubations were identified correctly. Only 72% of the students listened to the epigastrium, 81% listened to the lungs, and 85% attempted ventilation. The 10 students who visualized the cords discovered all five esophageal intubations. The 23 students who did not visualize the cords missed four and found six esophageal intubations. Basic EMTs had difficulty assessing endotracheal tube placement in a mannequin model. The 27% miss rate for identifying esophageal intubations suggests that basic EMTs will require additional training for safe field use of any airway that requires assessment of tube placement.

Issues of Consent: The Use of the Recently Deceased for Endotracheal Intubation Training

Issues of Consent: The Use of the Recently Deceased for Endotracheal Intubation Training

Invasive airway techniques in resuscitation

Although endotracheal intubation is still the most definitive technique for airway management in patients with cardiac or respiratory arrest, in some emergency care systems, use of endotracheal intubation by prehospital care personnel has been restricted by policy or statute. Therefore, alternative airway devices have been developed. These alternative airway devices include the Esophageal Obturator Airway (EOA) and Esophageal Gastric Tube Airway (EGTA), the Pharyngeotracheal Lumen Airway (PTL), and the Esophageal-Tracheal Combitube (ETC). By examining the available literature concerning these alternative airway devices, we sought to determine 1) if these devices are superior to basic, noninvasive airway techniques (eg, bag-valve-mask ventilation); 2) if they are comparable to endotracheal intubation in terms of ventilation, oxygenation, and potential complications; 3) what the role of these devices should be in prehospital care; and 4) what the best recommendations should be regarding these devices in terms of resuscitation training and future areas for research. The review involved a total of 837 EOA/EGTA, 304 PTL, and 159 ETC study patients. Although ventilation and oxygenation can, in some circumstances, be as good with the EOA/EGTA devices as it is with the endotracheal intubation, in some cases they can be inadequate, and the complication rate is relatively high. Preliminarily, the PTL and the ETC seem to provide adequate ventilation and oxygenation with few complications. However, for both devices, published clinical experience, especially in the prehospital setting, is still limited. Therefore, their use should be left to the discretion of accountable physician directors of applicable resuscitation teams. Regardless of the device used, recognition of proper placement remains the most important aspect of using any invasive airway device. Therefore, proper training and expert medical supervision probably have more influence on the successful use and impact of these devices than any other factors related to the devices themselves. Future training efforts would be most useful if directed at proper endotracheal intubation training and development of improved basic ventilatory skills. Nevertheless, additional controlled, direct-comparison studies of the PTL and ETC devices are recommended and should be conducted in properly supervised emergency medical services systems.

Prospective study of manikin-only versus manikin and human subject endotracheal intubation training of paramedics

To determine the effect of manikin-only training on field success of endotracheal intubation by paramedics. Prospective evaluation of individual field endotracheal intubation success rates for paramedics after they participated in a manikin-only or a manikin-plus-cadaver training program. Paramedics responding to emergency calls involving adult medical or trauma victims. All participants were trained using a controlled manikin training program; then, half were randomly selected for additional instruction using fresh human cadavers. Individuals trained using only the manikin program had mean +/- SD individual success rates of 82 +/- 32%, and individuals who received additional cadaver training had mean individual success rates of 83 +/- 31%. Overall success rates for the two groups were 86% for the manikin-only group and 85% for the manikin-plus-cadaver-trained group. The sample size was not adequate to allow rejection of the null hypothesis. Paramedics trained in endotracheal intubation using a systematic manikin-only teaching program can attain acceptable individual success rates in the actual field setting.

The practice of teaching endotracheal intubation on recently deceased patients

There are few data available regarding the emergency department practice of using recently dead patients (RDP) for practice and training in endotracheal intubation (ETI/RDP). We investigated several aspects of practice by means of a survey sent to all 5,397 emergency departments in the country. Of the 992 (18.3%) responses, 537 (54.1%) did practice ETI/RDP; 455 (45.8%) did not ( P<0.005). ETI/RDP was used significantly more commonly for instruction of paramedics (411 institutions [77%]), than for other classes of health providers ( P<0.0001). Overall, only 69 emergency departments (7%) had any written policy governing ETURDP; even among those actually practicing ETI/RDP, 84% had no written policy. Likewise, patients and families were rarely informed of the practice. In institutions where ETI/RDP does occur, only 15 (3%) of emergency departments have a policy which mandates such notification. There was widespread agreement as to the educational value of the practice, although it was more favored in hospitals practicing ETI/RDP than those that do not: 411 of 418 (98%) hospitals practicing ETI/RDP agreed that it was an important component of medical education, as did 240 (80%) of institutions not practicing it ( P<0.0001). Nearly equal percentages of teaching hospitals (53.8%) and nonteaching facilities (57.9%) engage in ETI/RDP ( P=0.35). Objections to ETI/RDP had been noted in 25% of the institutions where it was practiced.

Use of Esophageal Gastric Tube Airway-Reply

In Reply.— We thank each of the authors for their thoughtful comments. Dr Mangold has succinctly reiterated our observations concerning the functional inadequacy of the EGTA. We commend his community for the establishment of endotracheal intubation training for paramedical personnel. We are unaware of any data that support Mr Fluck's contention that ventilation-perfusion matching improves spontaneously as cardiac resuscitation proceeds over time. In full cardiac arrest, cardiac output and perfusion deteriorate in a time-dependent fashion. Improvement in ventilation during cardiopulmonary resuscitation is a concept that may be supported in surfactant-deficient neonates or victims of submersion incidents but cannot be supported in routine resuscitations, wherein atelectasis plays an exceedingly minor role. Certainly, it cannot account for significant improvement over a five-minute period following a 20-minute resuscitation. As we noted in our discussion, no conclusion can be drawn from patients who cannot be adequately oxygenated or ventilated following endotracheal intubation, since they