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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
@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)%
0
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0.9
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0 20 40 60 80 100
Prob
abili
ty o
f opt
imal
intu
batio
n
Experience
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: [email protected] (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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40-80?
Bernhard et al. 2012 Acta Anaesthesiologica ScandinavicaCortellazzi et al. 2015 Anaesthesia
The pursuit & consequence of the search for easy…
1st A
ttem
pt S
ucce
ss R
ates
0
25
50
75
100
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
ucce
ss R
ates
0
25
50
75
100
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
43
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
8
- 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