Mastery of Videolaryngoscopy through Deliberate Practice

Va San Diego Healthcare System, San Diego CA

Investigators

Abstract

Videolaryngoscopy constitutes one of the significant advances in airway management over the last 20 years. Placing a chip at the end of the laryngoscope obviates the need to establish a line of sight path from the mouth to larynx, facilitates vocal cord visualization, shortens learning curves and makes endotracheal intubation easier at minimal levels of experience. The modality may make it rational to use ancillary providers such as respiratory therapists, medics or non-anesthetist physicians for emergency airway management in the 55% of VA hospitals that do not have service from more highly trained anesthesia personnel part or all of the time. Because of this system wide problem, a recent VA directive mandated airway management training for these non-traditional providers and suggested that videolaryngoscopy should be strongly considered for intubation when difficulty is expected. Videolaryngoscopy does not guarantee successful intubation, however. Anatomic characteristics in some patients make it difficult to pass the endotracheal tube past vocal cords that are in plain view with a videolaryngoscope, even for experienced anesthetists. This type of failure occurs in 20-30% of emergent videolaryngoscopy intubations. It compromises safety because failed intubations have a high risk of life-threatening respiratory and cardiovascular complications. Experts can overcome videolaryngoscopy difficulty, but an operator with minimal experience would be unlikely to find the appropriate techniques in an emergency. Our hypothesis is that non-experts can develop the skills for successful videolaryngoscopy in difficult patients by practicing on simulators and that these efforts will improve the safety of videolaryngoscopy. The project aims to produce multiple partial task trainers for teaching difficult videolaryngoscopy skills, develop a training program and test whether the program enables successful video intubation by novice providers in situations where an untrained operator would fail. The investigative team, including anesthesiologists and engineers, has already developed two prototype mannequins configured to simulate difficult videolaryngoscopy and plans to develop additional independent trainers. A previously developed instrumentation system, which display the positions of laryngoscope, endotracheal tube and larynx in real time, will assist in devising maneuvers that lead to successful intubation in the difficult mannequins. This instrumentation will also provide feedback to students during training. The training program will rely on graded exercises to develop individual motions, then maneuvers and strategies for successful intubation. This approach to teaching procedural skills is called deliberate practice. During the training, students will receive oral feedback from videolaryngoscopy experts and visual feedback from the position display. Pre- and post-training tests will provide evidence for effectiveness. We anticipate that simulation training will teach the special skills needed for difficult videolaryngoscopy. The ultimate objective is to enable a large population of providers, not just anesthetists, to provide safe emergency airway management in all VA hospitals and at all times, night and day.