Survey of video laryngoscopy use by U.S. critical care fellowship training programs

Factors influencing confidence in tracheal intubation among neonatal trainees: A questionnaire-based study

AIM

Tracheal intubation (TI) is pivotal in managing critically ill neonates. This study aims to investigate the disparities in exposure and training techniques that affect self-perceived confidence in neonatal fellows concerning TI.

METHODS

A comprehensive, structured questionnaire-based survey was conducted among neonatal trainees from October to November 2022. Self-perceived confidence in TI was evaluated using a Likert scale, ranging from 1 to 10. The trainees who scored below seven were categorised as under-confident, while those who scored seven or more were considered confident in TI. An analysis was done to assess the differences in exposure, training and clinical policies related to TI in both groups. A P-value <0.05 was considered significant.

RESULTS

The final dataset consisted of 93 trainees. Confidence was higher among those who had independently performed TI on more than 30 neonates during their postgraduate training (relative risk (RR) 1.5 (1.03-2.1), P = 0.02) and super-specialty training (RR 1.5 (1.20-1.93), P = 0.0004). Confidence was also significantly associated with training programmes that incorporated written checklists for intubation instruments and policies (RR 1.4 (1.1-1.8), P = 0.006), conducted debriefing sessions after each TI attempt (RR 1.3 (1.03-1.6), P = 0.005), and implemented regular simulation programmes (RR 1.4 (1.1-1.8), P = 0.0006).

CONCLUSIONS

Trainees with increased opportunities for intubation and training programmes featuring regular simulations and debriefing sessions tend to possess higher self-perceived confidence in TI.

The use of video laryngoscopy outside the operating room: A systematic review

This study aimed to describe how video laryngoscopy is used outside the operating room within the hospital setting. Specifically, we aimed to summarise the evidence for the use of video laryngoscopy outside the operating room, and detail how it appears in current clinical practice guidelines. A literature search was conducted across two databases (MEDLINE and Embase), and all articles underwent screening for relevance to our aims and pre-determined exclusion criteria. Our results include 14 clinical practice guidelines, 12 interventional studies, 38 observational studies. Our results show that video laryngoscopy is likely to improve glottic view and decrease the incidence of oesophageal intubations; however, it remains unclear as to how this contributes to first-pass success, overall intubation success and clinical outcomes such as mortality outside the operating room. Furthermore, our results indicate that the appearance of video laryngoscopy in clinical practice guidelines has increased in recent years, and particularly through the COVID-19 pandemic. Current COVID-19 airway management guidelines unanimously introduce video laryngoscopy as a first-line (rather than rescue) device.

Essentials of Neonatal-Perinatal Medicine fellowship: part 2 - clinical education and experience

This is the second article in a seven-part series in the Journal of Perinatology that aims to critically examine the current state of Neonatal-Perinatal Medicine (NPM) fellowship training from the structure and administration of a program, to the clinical and scholarly requirements, and finally to the innovations and future careers awaiting successful graduates. This article focuses on the current clinical requirements; recent changes to the clinical environment and their effect on learning; and additional challenges and opportunities in clinical education.

Variation in Intensive Care Unit Intubation Practices in Pulmonary Critical Care Medicine Fellowship

Background: Endotracheal intubation in the intensive care unit (ICU) is a high-risk procedure. Competence in endotracheal intubation is a requirement for Pulmonary and Critical Care Medicine (PCCM) training programs, but fellow experience as the primary operator in intubating ICU patients has not been described on a large scale.

Objective: We hypothesized that significant variation surrounding endotracheal intubation practices in medical ICUs exists in U.S. PCCM training programs.

Methods: We administered a survey to a convenience sample of U.S. PCCM fellows to elicit typical intubation practices in the medical ICU.

Results: Eighty-nine discrete U.S. PCCM and Internal Medicine Critical Care Medicine training programs (77% response rate) were represented. At 43% of programs, the PCCM fellow was “always or almost always” designated the primary operator for intubation of a medical ICU patient, whereas at 21% of programs, the PCCM fellow was “rarely or never” the primary operator responsible for intubating in the ICU. Factors influencing this variation included time of day, hospital policies, attending skill or preference, ICU census and acuity, and patient factors. There was an association between location of the training program, but not program size, and whether the PCCM fellow was the primary operator.

Conclusion: There is significant variation in whether PCCM fellows are the primary operators to intubate medical ICU patients during training. Further work should explore how this variation affects fellow career development and competence in intubation.

Simulation Training for Critical Care Airway Management: Assessing Translation to Clinical Practice Using a Small Video-Recording Device

BACKGROUND

Critical care airway management (CCAM) is a key skill for critical care physicians. Simulation-based training (SBT) may be an effective modality in training intensivists in CCAM.

RESEARCH QUESTION

Is SBT of critical care fellows an effective means of providing training in CCAM, in particular in urgent endotracheal intubation?

STUDY DESIGN AND METHODS

Thirteen first-year pulmonary critical care medicine (PCCM) fellows at an academic training program underwent SBT with a computerized patient simulator (CPS) in their first month of fellowship training. At the end of the training period, the fellows underwent video-based scoring using a 46-item checklist (of which 40 points could be scored) while performing a complete CCAM sequence on the CPS. They were then tested, using video-based scoring on their first real-life CCAM. Maintenance of skill at CCAM was assessed during the fellows' second and third year of training, using the same scoring method.

RESULTS

For the first-year fellows, the score on the CPS was 38.3 ± 0.75 SD out of a maximum score of 40. The score on their first real-life patient CCAM was 39.0 ± 0.81 SD (P = .003 for equivalence; 95% CI for difference between real-life patient CCAM and CPS scores, 0.011-1.373). Sixteen second- and third-year fellows were tested at a real-life CCAM event later in their fellowship to examine for maintenance of skill. The mean maintenance of skill score of this group was 38.7 ± 1.14 SD.

INTERPRETATION

Skill acquired through SBT of critical care fellows for CCAM transfers effectively to the real-life patient care arena. Second- and third-year fellows who had initially received SBT maintained skill at CCAM.

What Do NICU Fellows Identify as Important for Achieving Competency in Neonatal Intubation?

BACKGROUND

Tracheal intubation (TI) is one of the most important interventions for the stabilization of critically ill neonates. Competency in airway management is essential for neonatal fellows. No studies have assessed which educational models, techniques, or instructions are perceived by neonatal fellows as the most beneficial for achieving competency in TI.

OBJECTIVES

This study identifies which factors are considered most helpful in achieving intubation competency.

METHOD

This was a mixed-method study. Semi-structured phone interviews addressed training experience for neonatal intubation. Through qualitative analysis, common themes were identified. RedCap electronic surveys and procedure logs were used to assess procedural experience.

RESULTS

Forty-two fellows from 5 programs completed phone interviews. Fellows recalled 6-10 intubation attempts before fellowship. Independent statements related to achieving intubation competency were analyzed and coded into 5 main themes (Procedure, Practice, Perceptual Environment, Personnel, and Preparation). A large proportion of the statements focused on the use of video laryngoscopy.

CONCLUSIONS

The themes identified by neonatal-perinatal medicine (NPM) fellows as being the most beneficial in achieving proficiency in neonatal TI are categorized as "The 5 Ps." Careful review of these themes may be utilized to develop validated curriculums that enhance the teaching of TI and optimize the achievement of TI competency among NPM fellows.

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit

RATIONALE

Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy.

OBJECTIVES

To identify characteristics associated with first-attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU).

METHODS

This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single-center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation.

MEASUREMENTS AND MAIN RESULTS

There were no significant differences in sex, age, reason for intubation, or device used between first-attempt failures and first-attempt successes. First-attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7-27.0% vs. 13.3%; 95% CI, 8.0-18.8%). In logistic regression analysis of the entire 906-patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64-4.20), airway edema (OR, 2.85; 95% CI, 1.48-5.45), and obesity (OR, 1.59; 95% CI, 1.08-2.32) were significantly associated with first-attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60-4.64), cervical immobility (OR, 3.34; 95% CI, 1.28-8.72), and airway edema (OR, 3.10; 95% CI, 1.42-6.70) were associated with first-attempt failure.

CONCLUSIONS

In this single-center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first-attempt failure, when intubation was performed with video laryngoscopy in an ICU.

Video versus direct laryngoscopy on successful first-pass endotracheal intubation in ICU patients

BACKGROUND

Airway management in intensive care unit (ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy (DL) and that by using the video laryngoscopy (VL).

METHODS

A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success.

RESULTS

A total of 163 ICU patients underwent intubation during the study period (81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group (67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications (all P>0.05).

CONCLUSION

Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.

Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults

OBJECTIVE

To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

DESIGN

A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

SETTING

Medical ICU in a tertiary, academic medical center.

PATIENTS

Critically ill patients 18 years old or older.

INTERVENTIONS

Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS

Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

CONCLUSIONS

In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Video Laryngoscopy Improves Odds of First-Attempt Success at Intubation in the Intensive Care Unit. A Propensity-matched Analysis

RATIONALE

Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited.

OBJECTIVES

To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit.

METHODS

We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding.

MEASUREMENTS AND MAIN RESULTS

A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2-83.3%) compared with 65.4% (95% CI, 56.8-73.4%) for intubations performed with direct laryngoscopy (P < 0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27-3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%; P = 0.008).

CONCLUSIONS

Video laryngoscopy was associated with significantly improved odds of first-attempt success at tracheal intubation by nonanesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

Retention of laryngoscopy skills in medical students: a randomised, cross-over study of the Macintosh, A.P. Advance(™) , C-MAC(®) and Airtraq(®) laryngoscopes

In addition to being effective and easy to learn how to use, the ideal laryngoscope should be associated with minimal reduction in skill performance during gaps in practice over time. We compared the time taken to intubate the trachea of a manikin by novice medical students immediately after training, and then after 1 month, with no intervening practice. We designed a two-period, four-group, randomised, cross-over trial to compare the Macintosh, Venner(™) A.P. Advance(™) with difficult airway blade, C-MAC(®) with D-Blade and Airtraq(®) with wireless video-viewer. A bougie was used to aid intubation with the Macintosh and the C-MAC. After training, there was no significant difference in median (IQR [range]) intubation time using the videolaryngoscopes compared with the Macintosh, which took 30 (26.5-35 [12-118])s. One month later, the intubation time was longer using the C-MAC (41 (29.5-52 [20-119])s; p = 0.002) and A.P. Advance (40 (28.5-57.5 [21-107])s; p = 0.0003)m compared with the Macintosh (27 (21-29 [16-90])s); there was no difference using the Airtraq (27 (20.5-32.5 [15-94])s; p = 0.258) compared with the Macintosh. While skill acquisition after a brief period of learning and practice was equal for each laryngoscope, performance levels differed after 1 month without practice. In particular, the consistency of performance using the C-MAC and A.P. Advance was worse compared with the Macintosh and the Airtraq. While the clinical significance of this is doubtful, we believe that reliable and consistent performance at laryngoscopy is desirable; for the devices that we tested, this requires regular practice.

The impact of a comprehensive airway management training program for pulmonary and critical care medicine fellows. A three-year experience

RATIONALE

Airway management in the intensive care unit (ICU) is challenging, as many patients have limited physiologic reserve and are at risk for clinical deterioration if the airway is not quickly secured. In academic medical centers, ICU intubations are often performed by trainees, making airway management education paramount for pulmonary and critical care trainees.

OBJECTIVES

To improve airway management education for our trainees, we developed a comprehensive training program including an 11-month simulation-based curriculum. The curriculum emphasizes recognition of and preparation for potentially difficult intubations and procedural skills to maximize patient safety and increase the likelihood of first-attempt success.

METHODS

Training is provided in small group sessions twice monthly using a high-fidelity simulation program under the guidance of a core group of two to three advanced providers. The curriculum is designed with progressively more difficult scenarios requiring critical planning and execution of airway management by the trainees. Trainees consider patient position, preoxygenation, optimization of hemodynamics, choice of induction agents, selection of appropriate devices for the scenario, anticipation of difficulties, back-up plans, and immediate postintubation management. Clinical performance is monitored through a continuous quality improvement program.

MEASUREMENTS AND MAIN RESULTS

Sixteen fellows have completed the program since July 1, 2013. In the 18 months since the start of the curriculum (July 1, 2013-December 31, 2014), first-attempt success has improved from 74% (358/487) to 82% (305/374) compared with the 18 months before implementation (P = 0.006). During that time there were no serious complications related to airway management. Desaturation rates decreased from 26 to 17% (P = 0.002). Other complication rates are low, including aspiration (2.1%), esophageal intubation (2.7%), dental trauma (0.8%), and hypotension (8.3%). First-attempt success in a 6-month period after implementation (July 1, 2014-December 31, 2014) was significantly higher (82.1 compared with 70.9%, P = 0.03) than during a similar 6-month period before implementation (July 1, 2012-December 31, 2012).

CONCLUSIONS

This comprehensive airway curriculum is associated with improved first-attempt success rate for intensive care unit intubations. Such a curriculum holds the potential to improve patient care.