Practicing Mechanics of Intubation

Live Patient Practice

Laryngoscopy, intubation and airway procedural training is commonly taught in elective anesthesia settings. Although this provides a real tissue experience the clinical setting creates problems that severely limit the training experience. Patient safety is the priority and procedures cannot be repetitively done just for practice.  The visual restrictions inherent to direct laryngoscopy are a  great impediment to skill acquisition even in elective situations. The trainee cannot effectively visualize critical anatomy prior to doing the procedure themselves.  Additionally, when the trainee attempts laryngoscopy for the first time the supervisor is unable provide targeted feedback because two people cannot simultaneously sight the larynx. Initial laryngoscopy and intubation training is not appropriate in emergency settings where outcomes correlate with avoidance of prolonged and repetitive intubation attempts

The Airway Cam head-mounted imaging system invented by Dr. Richard Levitan in 1994 permits video display of the operator’s monocular perspective during laryngoscopy.  When Airway Cam videos are watched prior to initial laryngoscopy training novice intubators have a much higher success rate; a 90% success rate is achieved within 10 attempts, compared to 40 or 50 attempts if the trainee only receives mannequin training:

Levitan RM, Goldman TS, Bryan DA, Shofer F, Herlich A. Training with video imaging improves the initial intubation success rates of paramedic trainees in an operating room setting. Ann Emerg Med. 2001; 37: 46-50.

The Storz C-Mac video system has a CMOS miniature video camera embedded in a curved blade laryngoscope. This offers the trainee an opportunity for direct laryngoscopy experience while the camera provides for the supervisor a close up view of the larynx, blade tip positioning, and tube placement. Several studies have demonstrated the benefits of this in teaching settings:

Howard-Quijano KJ, Huang YM, Matevosian R, Kaplan MB, Steadman RH. Video-assisted instruction improves the success rate for tracheal intubation by novices. Br J Anaesth. 2008; 101: 568-72.

Low D, Healy D, Rasburn N. The use of the BERCI DCI Video Laryngoscope for teaching novices direct laryngoscopy and tracheal intubation. Anaesthesia. 2008; 63:195-201.

Other video laryngoscopes such as the Glidescope and McGrath, and optical laryngoscopes like the AirTraq (when connected to a camera system) are also a great way for novices to at least visualize real anatomy, even if they do not actually involve direct laryngoscopy.

In 2010, given the availability of direct laryngoscopy and other airway imaging, novice intubators should not land in an operating room setting and “learn as you go” (a.k.a. “LAYGO”) through trial and error.  This is a disservice to the trainee; trial and failure is not an effective way to instill self-confidence nor teach the subtleties of any airway management technique.  Novices should be taught a uniform “best practice” approach to the various techniques and not go from operating room to operating room getting anecdotal snippets from different supervisors.  The “roving intubation rotation” is also a disservice to the anesthesia supervisors who cannot effectively teach the procedure within the visual restrictions and time constraints involved.  Dr. Levitan believes that airway procedural practice is a privilege that the trainee should earn through intensive video education and mannequin practice (and ideally cadaver practice) prior to any anesthesia rotation.  In short, trainees should be “pre-flight” tested and certified that they understand the subtleties of a given airway technique before they do it.  They should have watched actual imaging of the procedure in many patients (and be able to narrate it in real time) before they try a specific intubation technique on an actual patient.

An under utilized opportunity for airway training is Otorhinolaryngology clinics.  In most academic medical centers nasoendoscopy is done hundreds of times per week in outpatient settings. Along with video stroboscopy and other imaging, nasoendoscopy offers a great way to learn laryngeal and airway anatomy across a wide variety of patients, with minimal patient risk.

Flexible fiberoptic intubation is among the most challenging airway techniques to learn and most clinical settings offer limited actual practice opportunities.  While it is standard for airway training classes to offer mannequin practice with long fiberscopes, real tissue experience is limited to only a few courses.  The Society of Airway Management in the U.S. has offered anesthetized animal practice at its annual meetings. Dr. Andrak Ovassapian a pioneer of fiberoptics in the U.S., runs small group airway fellowships at the University of Chicago providing fiberoptic training. In the U.K. the Norwich Endoscopic Airway Training Course specifically focuses on flexible fiberoptics.  Participants pass endoscopes on each other. The links to these training opportunities are listed below:

Society for Airway Management

University of Chicago Airway Study and Training Center

The Norwich Endoscopic Airway Training Course