Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
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The document discusses airway management and the skills required for successful intubation, emphasizing the importance of training and practice. A systematic review indicates that at least 50 endotracheal intubations (ETIs) are necessary for training healthcare providers to achieve a proficiency rate of 90%, particularly in elective situations. It highlights the challenges novices face, especially in emergency settings where the likelihood of difficult airways increases significantly.
![during laryngoscopy is supported by the findings of
Nouruzi-Sedeh et al., who found that the main diffi-
culty for novices was in obtaining a good laryngeal
view within 120 s [12]. In addition, Aziz et al. found a
65% incidence of failure involving inadequate laryngeal
views in a observational study of 2004 GlideScope
intubations [23].
The findings of this study are limited in that it
includes a small number of individuals in a single
institution, with the possibility that the findings may
not generalise to other institutions. However, the large
number of intubations studied, the statistical homoge-
neity of subjects/case difficulty and the gradual pro-
0
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0.2
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0.5
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0.9
1
0 20 40 60 80 100
Probabilityofoptimalintubation
Experience
Figure 1 The probability of optimal intubation pre-
dicted by mixed-effects logistic regression model.
Cortellazzi et al. | GlideScopeâ
tracheal intubation expertise Anaesthesia 2014
75? >100?
Resuscitation xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Review article
Defining the learning curve for endotracheal intubation using direct
laryngoscopy: A systematic reviewଝ,ଝଝ
Maria L. Buis∗Q1 , Iscander M. Maissan, Sanne E. Hoeks, Markus Klimek, Robert J. Stolker
Department 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 2015
Received in revised form 4 November 2015
Accepted 11 November 2015
Keywords:
Learning curve
Direct laryngoscopy
Intubation
a b s t r a c t
More than two failed intubation attempts and failed endotracheal intubations (ETIs) are associated with
severe complications and death. The aim of this review was to determine the number of ETIs a health care
provider in training needs to perform to achieve proficiency within two attempts. A systematic search of
the literature was conducted covering the time frame of January 1990 through July 2014. We identified
13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This review
shows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attempts
need 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 to
elective settings. Taking this factor into account, training should include a variety of exposures and should
probably exceed 50 ETIs to successfully serve the most vulnerable patients.
© 2015 Published by Elsevier Ireland Ltd.
Introduction
Q3
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, cardiac
arrest, brain damage, and mortality.3–6 The most critical patients
deserve the best-skilled health care providers, and the more
experienced the physician, the higher the chance of a successful
intubation.7 As for all manual skills, ETI is subject to a learning
curve.8
ETI skills should be developed in a structured training pro-
gramme, which is especially relevant for those who intubate in
non-elective or emergency settings where the incidence of a dif-
ficult or failed intubation is up to 20 times higher than in the
elective setting.3 In the Netherlands, training programmes for non-
anaesthesiologists who perform ETIs currently do not require a
minimum number of completed ETIs.9
The aim of the present study was to provide a systematic review
of the literature on the learning curve for ETIs. Because direct
ଝ A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.11.005.
ଝଝ 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-hospital
and in-hospital, we reviewed the learning curves for this proce-
dure. We specifically aimed to identify the number of ETIs a novice
intubator 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 Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) state-
ment. A search of the literature (January 1990–July 2014) was
performed using EMBASE, MEDLINE, Web of Science, Cochrane
Central Register of Controlled Trials (CENTRAL), and PubMed. The
following keywords were used for the search: ‘intubation’, ‘learn-
ing curve’, and ‘laryngoscopy’. The search was limited by excluding
the keywords ‘videolaryngoscopy’ and ‘paediatrics’. The full elec-
tronic searches can be found in Appendix A. In addition, we hand
searched the reference sections of all articles that were selected for
review.
Inclusion criteria were English-language only, human studies
only, DL as the sole procedure, novice participants or number of
previously performed intubations clearly identifiable, and speci-
fied quantification of the success rate learning curve for ETI. Studies
were excluded if they had been conducted in a simulation labora-
tory, were limited to paediatric patients only, involved ETI using a
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40-80?
Bernhard et al. 2012
Acta Anaesthesiologica Scandinavica
Cortellazzi et al. 2015 Anaesthesia](https://image.slidesharecdn.com/14-161123023706/85/Anyone-Can-Intubate-or-Not-Teaching-airway-skills-the-antifragile-way-34-320.jpg)
Anyone Can Intubate, or Not: Teaching airway skills the antifragile way
- 1. Anyone Can Intubate or 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 [email protected] @kovacsgj AIMEairway.ca
- 4. 4
- 5. 5
- 6. 6
- 8. 355
- 23. Success… • 90 % FPS • >90 % sat • >90 mm Hg • <90 sec
- 27. Competence/Performance Do Show how Know how Know Miller GE. The assessment of clinical skills/competence/performance. Acad Med.1990
- 30. “The greats weren’t great cause at birth they could paint. The greats were great cause they painted a lot.”
- 32. Math 101 • Owning the airway?
- 33. Math 101 • 75,000 Patient visits • 500 ETI’s/year • 9 shifts/day • 15 shifts/month • 2-3 resusc area/month • How many tubes?
- 34. during laryngoscopy is supported by the findings of Nouruzi-Sedeh et al., who found that the main diffi- culty for novices was in obtaining a good laryngeal view within 120 s [12]. In addition, Aziz et al. found a 65% incidence of failure involving inadequate laryngeal views in a observational study of 2004 GlideScope intubations [23]. The findings of this study are limited in that it includes a small number of individuals in a single institution, with the possibility that the findings may not generalise to other institutions. However, the large number of intubations studied, the statistical homoge- neity of subjects/case difficulty and the gradual pro- 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 20 40 60 80 100 Probabilityofoptimalintubation Experience Figure 1 The probability of optimal intubation pre- dicted by mixed-effects logistic regression model. Cortellazzi et al. | GlideScopeâ tracheal intubation expertise Anaesthesia 2014 75? >100? Resuscitation xxx (2015) xxx–xxx Contents lists available at ScienceDirect Resuscitation journal homepage: www.elsevier.com/locate/resuscitation Review article Defining the learning curve for endotracheal intubation using direct laryngoscopy: A systematic reviewଝ,ଝଝ Maria L. Buis∗Q1 , Iscander M. Maissan, Sanne E. Hoeks, Markus Klimek, Robert J. Stolker Department 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 2015 Received in revised form 4 November 2015 Accepted 11 November 2015 Keywords: Learning curve Direct laryngoscopy Intubation a b s t r a c t More than two failed intubation attempts and failed endotracheal intubations (ETIs) are associated with severe complications and death. The aim of this review was to determine the number of ETIs a health care provider in training needs to perform to achieve proficiency within two attempts. A systematic search of the literature was conducted covering the time frame of January 1990 through July 2014. We identified 13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This review shows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attempts need 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 to elective settings. Taking this factor into account, training should include a variety of exposures and should probably exceed 50 ETIs to successfully serve the most vulnerable patients. © 2015 Published by Elsevier Ireland Ltd. Introduction Q3 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, cardiac arrest, brain damage, and mortality.3–6 The most critical patients deserve the best-skilled health care providers, and the more experienced the physician, the higher the chance of a successful intubation.7 As for all manual skills, ETI is subject to a learning curve.8 ETI skills should be developed in a structured training pro- gramme, which is especially relevant for those who intubate in non-elective or emergency settings where the incidence of a dif- ficult or failed intubation is up to 20 times higher than in the elective setting.3 In the Netherlands, training programmes for non- anaesthesiologists who perform ETIs currently do not require a minimum number of completed ETIs.9 The aim of the present study was to provide a systematic review of the literature on the learning curve for ETIs. Because direct ଝ A Spanish translated version of the abstract of this article appears as Appendix in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.11.005. ଝଝ 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-hospital and in-hospital, we reviewed the learning curves for this proce- dure. We specifically aimed to identify the number of ETIs a novice intubator 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 Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) state- ment. A search of the literature (January 1990–July 2014) was performed using EMBASE, MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed. The following keywords were used for the search: ‘intubation’, ‘learn- ing curve’, and ‘laryngoscopy’. The search was limited by excluding the keywords ‘videolaryngoscopy’ and ‘paediatrics’. The full elec- tronic searches can be found in Appendix A. In addition, we hand searched the reference sections of all articles that were selected for review. Inclusion criteria were English-language only, human studies only, DL as the sole procedure, novice participants or number of previously performed intubations clearly identifiable, and speci- fied quantification of the success rate learning curve for ETI. Studies were excluded if they had been conducted in a simulation labora- tory, were limited to paediatric patients only, involved ETI using a 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 40-80? Bernhard et al. 2012 Acta Anaesthesiologica Scandinavica Cortellazzi et al. 2015 Anaesthesia
- 35. The pursuit & consequence of the search for easy…
- 36. 1stAttemptSuccessRates 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…
- 37. 1stAttemptSuccessRates 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
- 38. Tell me what you see?
- 39. Do you see the posterior cartridges?
- 41. 5 Faces Context
- 42. 7,000,000,000
- 43. 43
- 44. High Acuity Low Opportunity Challenge Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013 High Acuity Low Opportunity Low Acuity Low Opportunity High Acuity High Opportunity Low Acuity High Opportunity Opportunity Acuity Sim Zone Overlearn
- 48. These are your vitals
- 49. Times of stress Challenge Threat
- 50. Grossman & Christensen. On Combat 2008
- 51. Don’t avoid failure …be antifragile
- 52. High Acuity Low Opportunity Challenge Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013 High Acuity Low Opportunity Low Acuity Low Opportunity High Acuity High Opportunity Low Acuity High Opportunity Opportunity Acuity Sim Zone Overlearn System 1 training
- 53. 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 its smallest, most fundamental components. - Operators should master a regimented series of best-practice steps that are small, reliable, and reproducible. Expertise is the ability to do each task well, transforming incrementalized steps into 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, by flattening the slope, and lightening the load. - Slope: Incrementalization - Load: Cognition
- 54. System 1 training: Avoid Insanity I can’t see %$^&!!!
- 55. System 1 training: Cued Response • Epiglottoscopy • Valleculoscopy • Laryngoscopy • Intubation AIMEairway.ca: SMACC Byte- Airway Management Kata Epiglottis only response
- 56. Cued Response: Psychomotor rehearsal EVLI Learn as Many/Execute as 1
- 57. Best Look DL&I Cued Response: Psychomotor rehearsal Learn as Many/Execute as 1
- 59. “we all got plans, til you get punched in the mouth” Confidence
- 60. Number Needed to be… Confident
- 62. Good judgment is the result of experience and experience the result of bad judgment
- 65. It’s not about you
- 66. Its about the patient
- 70. Plan A Plan CPlan B Airway Tool Box Do Know
- 71. Plan A Plan CPlan B Airway Tool Box Do Know
- 80. Thank You