Anyone Can Intubateor Not

Teaching & Learning Airway Management the Antifragile Way

George Kovacs MD MHPE FRCPC Professor, Departments of Emergency Medicine, Anaesthesia

Medical Neuroscience & Division of Medical Education Dalhousie University, Halifax Nova Scotia

gkovacs@dal.ca

@kovacsgj

AIMEairway.ca

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@kovacsgj AIMEairway.ca

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Anyone Can Intubate!!

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Successful Airway Management

First Pass Success

Success…• 90 % FPS • >90 % sat • >90 mm Hg • <90 sec

Becoming Successful

CompetenceContext

Confidence Conscientiousness

CompetenceContext

Confidence Conscientiousness

Avoiding Failure ?

Competence

ProgramPractice

Feedback

Competence/Performance

Do

Show how

Know how

KnowMiller GE. The assessment of clinical skills/competence/performance. Acad Med.1990

Does

Competence

Performance

How Much Practice

“The greats weren’t great cause at birth they could paint. The greats were great cause they

painted a lot.”

Practice- How often?

Math 101• Owning the airway?

Math 101• 75,000 Patient visits • 500 ETI’s/year • 9 shifts/day • 15 shifts/month • 2-3 resusc area/month

• How many tubes?

superiority of any new technique or device [25]. Thisis exemplified by the study by Siu et al. whichdescribed a first-attempt success rate of 86.6% after20–29 intubations, but which did not include grade oflaryngeal view in their outcomes [13]. It appears likelythat while their subjects were able to intubate in a highproportion of cases, their technique had not advancedto the point where they were able to achieve the bestpossible laryngeal view routinely. Inclusion of thelaryngeal view as an outcome allows the progress ofthe subject to be measured past the point of success(minimal competence) towards true expertise.

Although obtaining a good laryngeal view doesnot exclude failure [8, 22], the importance of achievingand maintaining a Cormack and Lehane grade-1 view

during laryngoscopy is supported by the findings ofNouruzi-Sedeh et al., who found that the main diffi-culty for novices was in obtaining a good laryngealview within 120 s [12]. In addition, Aziz et al. found a65% incidence of failure involving inadequate laryngealviews in a observational study of 2004 GlideScopeintubations [23].

The findings of this study are limited in that itincludes a small number of individuals in a singleinstitution, with the possibility that the findings maynot generalise to other institutions. However, the largenumber of intubations studied, the statistical homoge-neity of subjects/case difficulty and the gradual pro-gress of trainees towards the performance of theirsupervisors support the validity of the findings. Videorecordings as used by Mulcaster et al. could haveimproved objectivity, and could have proved useful inextracting the critical tasks necessary for a successfulintubation [5]. However, while the video imagesrecorded by the GlideScope itself can provide anassessment of the trainee’s skill in positioning thelaryngoscope and sliding the tube into the trachea,additional external video recording would be requiredto capture body position and problems such as therecognised ‘blind spot in the oropharynx’ [26].Although the use of a non-clinical observer may havereduced bias, we recognise that it may have introducederrors through non-recognition of some aspects ofclinical practice [22]. This study was also not able toidentify other aspects of performance, for example,whether expertise with direct laryngoscopy is necessaryto become proficient with the GlideScope [13], andwhether de-skilling over time would limit the useful-ness of videolaryngoscopy as a rescue technique for arare event such as unpredicted difficult intubation. Itmust also be noted that the rigorous pre-operative air-way assessment would have excluded almost allpatients with particularly difficult airways, and thateven optimal performance could not be assumed topredict likely success in more challenging circum-stances.

This study suggests that videolaryngoscopy is acomplex skill that requires extensive practice to achieveexpertise, even in those trained in direct laryngoscopy.It further suggests that expertise is best defined by acombination of objective and subjective criteria

Table 4 Change in performance of subjects with expe-rience. Values are mean (SD) time or mean (1.96 9SE) proportion.

Experience(intubationscompleted)

Total timeto intubate; s

Optimalintubations

1–10 (n = 9) 48.09 (33.9) 44 (10)%11–20 (n = 9) 37.85 (19.4) 61 (10)%21–30 (n = 9) 32.99 (20.9) 78 (9)%31–40 (n = 9) 30.79 (18.0) 80 (8)%41–50 (n = 9) 29.10 (13.6) 80 (8)%51–60 (n = 9) 28.41 (15.5) 82 (8)%61–70 (n = 9) 25.60 (14.0) 89 (7)%71–80 (n = 9) 23.26 (10.5) 91 (6)%81–90 (n = 6) 22.54 (12.0) 92 (7)%91–100 (n = 6) 22.79 (9.9) 88 (8)%

101–110 (n = 5) 21.33 (11.1) 92 (8)%Control group (n = 72) 22.82 (9.9) 89 (7)%

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Figure 1 The probability of optimal intubation pre-dicted by mixed-effects logistic regression model.

© 2014 The Association of Anaesthetists of Great Britain and Ireland 5

Cortellazzi et al. | GlideScope! tracheal intubation expertise Anaesthesia 201475? >100?

Please cite this article in press as: Buis ML, et al. Defining the learning curve for endotracheal intubation using direct laryngoscopy: Asystematic review. Resuscitation (2015), http://dx.doi.org/10.1016/j.resuscitation.2015.11.005

ARTICLE IN PRESSG ModelRESUS 6602 1–9

Resuscitation xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Resuscitationjo u r n al homep age : www.elsev ier .com/ locate / resusc i ta t ion

Review article

Defining the learning curve for endotracheal intubation using directlaryngoscopy: A systematic review!,!!

Maria L. Buis ∗Q1 , Iscander M. Maissan, Sanne E. Hoeks, Markus Klimek, Robert J. StolkerDepartment of Anaesthesiology, Erasmus University Medical Centre, Office H-1286, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsQ2

a r t i c l e i n f o

Article history:Received 31 July 2015Received in revised form 4 November 2015Accepted 11 November 2015

Keywords:Learning curveDirect laryngoscopyIntubation

a b s t r a c t

More than two failed intubation attempts and failed endotracheal intubations (ETIs) are associated withsevere complications and death. The aim of this review was to determine the number of ETIs a health careprovider in training needs to perform to achieve proficiency within two attempts. A systematic search ofthe literature was conducted covering the time frame of January 1990 through July 2014. We identified13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This reviewshows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attemptsneed to be performed to reach a success rate of at least 90%. However, the evidence is heterogeneous,and the incidence of difficult airways in non-elective settings is up to 20 times higher compared toelective settings. Taking this factor into account, training should include a variety of exposures and shouldprobably exceed 50 ETIs to successfully serve the most vulnerable patients.

© 2015 Published by Elsevier Ireland Ltd.

IntroductionQ3

Failed intubation is the most frequently reported complica-tion in airway management according to a recent British survey.1,2

Numerous (>2) attempts and failed endotracheal intubations (ETIs)are associated with oxygen desaturation, arrhythmias, cardiacarrest, brain damage, and mortality.3–6 The most critical patientsdeserve the best-skilled health care providers, and the moreexperienced the physician, the higher the chance of a successfulintubation.7 As for all manual skills, ETI is subject to a learningcurve.8

ETI skills should be developed in a structured training pro-gramme, which is especially relevant for those who intubate innon-elective or emergency settings where the incidence of a dif-ficult or failed intubation is up to 20 times higher than in theelective setting.3 In the Netherlands, training programmes for non-anaesthesiologists who perform ETIs currently do not require aminimum number of completed ETIs.9

The aim of the present study was to provide a systematic reviewof the literature on the learning curve for ETIs. Because direct

! A Spanish translated version of the abstract of this article appears as Appendixin the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.11.005.!! This review was presented at the Dutch Anaesthesiology Congress, May 29,

2015, Maastricht, The Netherlands.∗ Corresponding author.

E-mail address: m.buis@erasmusmc.nl (M.L. Buis).

laryngoscopy (DL) is the most widely used technique pre-hospitaland in-hospital, we reviewed the learning curves for this proce-dure. We specifically aimed to identify the number of ETIs a noviceintubator must perform to achieve proficiency with this procedure,defined as successfully intubating within two attempts.

Methods

Study selection

This review was performed according to the Preferred ReportingItems for Systematic Reviews and Meta-Analyses (PRISMA) state-ment. A search of the literature (January 1990–July 2014) wasperformed using EMBASE, MEDLINE, Web of Science, CochraneCentral Register of Controlled Trials (CENTRAL), and PubMed. Thefollowing keywords were used for the search: ‘intubation’, ‘learn-ing curve’, and ‘laryngoscopy’. The search was limited by excludingthe keywords ‘videolaryngoscopy’ and ‘paediatrics’. The full elec-tronic searches can be found in Appendix A. In addition, we handsearched the reference sections of all articles that were selected forreview.

Inclusion criteria were English-language only, human studiesonly, DL as the sole procedure, novice participants or number ofpreviously performed intubations clearly identifiable, and speci-fied quantification of the success rate learning curve for ETI. Studieswere excluded if they had been conducted in a simulation labora-tory, were limited to paediatric patients only, involved ETI using a

http://dx.doi.org/10.1016/j.resuscitation.2015.11.0050300-9572/© 2015 Published by Elsevier Ireland Ltd.

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Bernhard et al. 2012 Acta Anaesthesiologica ScandinavicaCortellazzi et al. 2015 Anaesthesia

The pursuit & consequence of the search for easy…

1st A

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ucce

ss R

ates

0

25

50

75

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Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2014 Hypes 2016 Total

VL

DL 68%

80%

Total ~2500 in each DL & VL

In pursuit of easy… VL is better…

1st A

ttem

pt S

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ss R

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25

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Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2014 Hypes 2016 Total

VL

DL 68%

80%17,000 Registry PatientsDL 84%

In pursuit of easy… VL is better than bad DL

Tell me what you see?

Do you see the posterior cartridges?

CompetenceContext

Confidence Conscientiousness

Context: materials

5 Faces

Context

7,000,000,000

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High Acuity Low Opportunity Challenge

Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013

High AcuityLow Opportunity

Low Acuity Low Opportunity

High Acuity High Opportunity

Low Acuity High Opportunity

Opportunity

Acuity

Sim Zone

Overlearn

Opportunities… Overlearn

Opportunities… Overlearn

Context: environment

High

Stakes

These are your vitals

Times of stress

Challenge Threat

Grossman & Christensen. On Combat 2008

Don’t avoid failure

…be antifragile

High Acuity Low Opportunity Challenge

Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013

High AcuityLow Opportunity

Low Acuity Low Opportunity

High Acuity High Opportunity

Low Acuity High Opportunity

Opportunity

Acuity

Sim Zone

Overlearn

System 1 training

System 1 training Learn as Many/Execute as 1

Incrementalization

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- The “secret “ of competence in crisis is to break down the challenge into smaller parts, and then incrementalize it into itssmallest, most fundamental components.

- Operators should master a regimented series of best-practicesteps that are small, reliable, and reproducible. Expertise is theability to do each task well, transforming incrementalized stepsinto one fluid, apparently easy, and effortless movement.

- Slow is smooth and smooth is fast. Rushing deteriorates performance.  Multi-tasking is a myth.

- Procedures should be engineered for crisis performance, byflattening the slope, and lightening the load.

- Slope: Incrementalization- Load: Cognition

System 1 training: Avoid Insanity

I can’t see %$^&!!!

System 1 training: Cued Response

• Epiglottoscopy

• Valleculoscopy

• Laryngoscopy

• Intubation

AIMEairway.ca: SMACC Byte- Airway Management Kata

Epiglottis only response

Cued Response: Psychomotor rehearsal

EVLI

Learn as Many/Execute as 1

Best Look DL&I

Cued Response: Psychomotor rehearsalLearn as Many/Execute as 1

CompetenceContext

Confidence Conscientiousness

Confidence

“we all got plans, til you get punched in the mouth”

Confidence

Number Needed to be… Confident

Confidence

Experience

Con

fiden

ce

Good judgment is the result of experience and experience the result of

bad judgment

Conscientiousness

Competence

Confidence

Context

64

… work ethically Conscientiousness

It’s not about you

Its about the patient

67

Conscientiousness … work ethic

68

Conscientiousness … work ethic

69

Conscientiousness

DoingKnowing

… work ethic

Plan A

Plan CPlan B

Airway Tool Box

DoKnow

Plan A

Plan CPlan B

Airway Tool Box

DoKnow

Fear of Failure

Competence Context

ConfidenceConscientiousness

Anybody can intubate

Anybody can intubate

Competence Context

ConfidenceConscientiousness

Anyone can intubate

Thank You