Anaesthesia trainees' exposure to airway management in an Australian tertiary adult teaching hospital

The purpose of this study was to estimate the exposure of trainees to airway management techniques in an Australian tertiary adult teaching hospital. Anaesthesia records for all patients over a 20-week period were reviewed and the following data were obtained: the presence of a trainee, the type of airway used, the grade of the laryngoscopic view and the use of non-standard laryngoscopy for intubation. Data was recorded contemporaneously and analysed retrospectively. The data was then extrapolated to give a yearly estimate of airway procedures per trainee. There were 28 full-time trainees in the department over the study period. The estimated mean number of standard intubations performed per trainee per year was 157.4, with 2.9% being grade 3 or 4 laryngoscopies. The estimated mean annual numbers for other airway techniques were: 1.2 fibreoptic intubations, 0.5 mask-only anaesthetics and 3.7 endobronchial double-lumen tubes. Our results suggest that trainees' exposure to airway management techniques is not extensive. As there is no previous study to determine experience gained by trainees, we are unable to establish whether there has been a decrease in experience, however we believe this is likely. Although competency is difficult to assess, it may be that this data has implications for training, unsupervised practice and rostering. Experience in certain airway skills may need to be supplemented using techniques such as simulation.     

Prehospital airway management: A prospective case study

We conducted a one-year prospective study involving a prehospital Emergency Medical Service in the Netherlands to investigate the incidence of failed or difficult prehospital endotracheal intubation. During the study period the paramedics were asked to fill in a registration questionnaire after every endotracheal intubation. Of the 26,271 patient contacts, 256 endotracheal intubations were performed by paramedics in one year. Endotracheal intubation failed in 12 patients (4.8%). In 12.0% of 249 patients, a Cormack and Lehane grade III laryngoscopy was reported and a grade IV laryngoscopy was reported in 10.4%. The average number of endotracheal intubations per paramedic in one year was 4.2 and varied from zero to a maximum of 12. The median time between arrival on the scene and a positive capnograph was 7 min.38 s in the case of a Cormack and Lehane grade I laryngoscopy and 14 min.58 s in the case of a Cormack and Lehane grade 4 laryngoscopy. The incidence of endotracheal intubations performed by Dutch paramedics in one year was low, but endotracheal intubation was successful in 95.2%, which is comparable with findings in international literature. Early capnography should be used consistently in prehospital airway management.     

Use of a fibreoptic stylet to visually evaluate tracheal intubation technique

To compare the tracheal intubation by novices with that of instructors, we videotaped the view obtained through a fibreoptic stylet during standard tracheal intubations with a Macintosh direct laryngoscope. The duration of visualization of the vocal cords was longer during intubation by instructors than during trainee attempts. The tracheal tube contact (with pharyngeal wall) time duration was higher during intubation attempts by trainees than instructors. The quality of the image of the vocal cords through the stylet was related to these video-view parameters. Our results demonstrated that visualization of the vocal cords by direct laryngoscope and manipulation of the tracheal tube in the oral cavity were different between anaesthesia trainees and instructors, and suggested that visually monitoring the tracheal intubation procedure through a fibreoptic stylet might be useful for the education of anaesthesia trainees.     

Fibreoptic intubation skills among anaesthetists in New Zealand

The aim of this study was to investigate methods of practice, assess skill level, and evaluate attitudes towards fibreoptic intubation in the anaesthetic community of New Zealand. A postal survey questionnaire was sent to all vocationally registered anaesthetists in New Zealand and to all New Zealand anaesthetic trainees registered with the Australian and New Zealand College of Anaesthetists. There were 611 survey questionnaires posted and 386 (63%) respondents. Almost all respondents (98% of specialists, 100% of trainees) had access to fibreoptic equipment in public and 92% of respondents performed fibreoptic intubation. The median number of fibreoptic intubations performed per year was 3 for consultants and 4 for trainees. Respondents were either self taught or colleague taught (82%). Most learnt the technique on patients (92%). There were 14% who considered themselves experienced, 30% competent, 34% adequate and 20% novice. Skills were maintained by clinical patient mix in 73%. Fibreoptic intubation was considered a skill required by all anaesthetists in 87%, and 66% considered it the gold standard for expected difficult airways. Lack of clinical cases requiring the skill and lack of practice were identified as the primary barriers to skill development. Consultants had greater opportunity to learn fibreoptic intubation skills during daily practice than trainees. Only 18% of trainees had a formal airway management program available to them at their place of work. There appears to be a need to increase available opportunities to perform fibreoptic intubation to enable maintenance and improvement of fibreoptic skills in our community. A formalized program of teaching fibreoptic intubation may offer greater opportunity for learning and skill development.     

Incidence of difficult intubation in intensive care patients: analysis of contributing factors

Difficulties in endotracheal intubation increase morbidity and mortality in intensive care patients. We studied the problem in surgical intensive care patients with the aim of risk reduction. Patients intubated in the intensive care unit were evaluated. The intubations were performed or supervised by anaesthetists following the algorithm valid at the time of the study. Fifty percent of the 198 intubations were performed by specialist anaesthetists, 41.5% by anaesthesia trainees and 8.5% by surgical trainees. The initial attempt was by direct laryngoscopy (n=173), flexible fibrescope (n=8) or blind nasal technique (n=17). When direct laryngoscopy failed (n=7), intubation was accomplished with an intubating laryngeal mask airway (n=5), Frova stylet (n=1) or fibrescope (n=1). Thirty percent were rated as easy, 47% as moderately easy and 23% as difficult. Difficult intubations were associated with a higher incidence of anatomic anomalies, difficult bag-mask ventilation and severe oxygen desaturation. Every intubation in the ICU setting should be considered potentially difficult. The existing algorithm should be modified to incorporate the American Society of Anesthesiologists difficult airway algorithm adapted to the needs of the intensive care unit. A training program for alternative methods of airway management for difficult intubations should be established.     

Failed tracheal intubation during obstetric general anaesthesia: a literature review

We reviewed the literature on obstetric failed tracheal intubation from 1970 onwards. The incidence remained unchanged over the period at 2.6 (95% CI 2.0 to 3.2) per 1000 anaesthetics (1 in 390) for obstetric general anaesthesia and 2.3 (95% CI 1.7 to 2.9) per 1000 general anaesthetics (1 in 443) for caesarean section. Maternal mortality from failed intubation was 2.3 (95% CI 0.3 to 8.2) per 100 000 general anaesthetics for caesarean section (one death per 90 failed intubations). Maternal deaths occurred from aspiration or hypoxaemia secondary to airway obstruction or oesophageal intubation. There were 3.4 (95% CI 0.7 to 9.9) front-of-neck airway access procedures (surgical airway) per 100 000 general anaesthetics for caesarean section (one procedure per 60 failed intubations), usually carried out as a late rescue attempt with poor maternal outcomes. Before the late 1990s, most cases were awakened after failed intubation; since the late 1990s, general anaesthesia has been continued in the majority of cases. When general anaesthesia was continued, a laryngeal mask was usually used but with a trend towards use of a second-generation supraglottic airway device. A prospective study of obstetric general anaesthesia found that transient maternal hypoxaemia occurred in over two-thirds of cases of failed intubation, usually without sequelae. Pulmonary aspiration occurred in 8% but the rate of maternal intensive care unit admission after failed intubation was the same as that after uneventful general anaesthesia. Poor neonatal outcomes were often associated with preoperative fetal compromise, although failed intubation and lowest maternal oxygen saturation were independent predictors of neonatal intensive care unit admission.     

Difficult and failed intubation in 3430 obstetric general anaesthetics*

A retrospective audit was performed of all obstetric general anaesthetics in our hospital over an 8 year period to determine the incidence of difficult and failed intubation. Data was collected from a number of sources to ensure accuracy. A total of 3430 rapid sequence anaesthetics were given. None of the patients had a failed or oesophageal intubation (95% CI, 0–1:1143). There were 23 difficult intubations (95% CI, 1:238–1:100). This was anticipated in nine cases, requiring awake fibreoptic intubation in three cases. Consultants or specialist registrars were involved in the management of all cases. We attribute the low incidence of airway complications to the above average rate of general anaesthesia in our hospital, senior cover and specialised anaesthetic operating department assistants.     

A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre

Contemporary data are lacking for procedural practice, training provision and outcomes for awake fibreoptic intubation in the UK. We performed a prospective cohort study of awake fibreoptic intubations at a tertiary centre to assess current practice. Data from 600 elective or emergency awake fibreoptic intubations were collected to include information on patient and operator demographics, technical performance and complications. This comprised 1.71% of patients presenting for surgery requiring a general anaesthetic, with the majority occurring in patients presenting for head and neck surgery. The most common indication was reduced mouth opening (26.8%), followed by previous airway surgery or head and neck radiotherapy (22.5% each). Only five awake fibreoptic intubations were performed with no sedation, but the most common sedative technique was combined target‐controlled infusions of remifentanil and propofol. Oxygenation was achieved with high‐flow, heated and humidified oxygen via nasal cannula in 49.0% of patients. Most operators had performed awake fibreoptic intubation more than 20 times previously, but trainees were the primary operator in 78.6% of awake fibreoptic intubations, of which 86.8% were directly supervised by a consultant. The failure rate was 1.0%, and 11.0% of awake fibreoptic intubations were complicated, most commonly by multiple attempts (4.2%), over‐sedation (2.2%) or desaturation (1.5%). The only significant association with complications was the number of previous awake fibreoptic intubations performed, with fewer complications occurring in the hands of operators with more awake fibreoptic intubation experience. Our data demonstrate that awake fibreoptic intubation is a safe procedure with a high success rate. Institutional awake fibreoptic intubation training can both develop and maintain trainee competence in performing awake fibreoptic intubation, with a similar incidence of complications and success compared with consultants.     

Airway experience of anaesthetic registrars

Education and expertise in airway skills are central components of anaesthesia training, yet there is no formal monitoring of the airway experience or level of competence that registrars actually obtain. An audit was performed in two phases to prospectively document the airway management experience of registrars in one teaching hospital department. Novices were studied for three months and subsequently, the whole registrar group for one month. Novice registrars performed a mean of two facemask anaesthetics, 19 laryngeal mask airways and 20 endotracheal intubations per month in their first three months of anaesthetic practice. The overall registrar group performed a mean of 18 laryngeal mask airways and 19 endotracheal intubations in the study month. Our findings indicate that the airway experience of anaesthesia trainees may be inadequate and therefore warrants further investigation.     

Intubation difficulties in patients with rheumatoid arthritis

Background : Fibreoptic intubation has been suggested to be the best method to manage a compromised airway. This retrospective study was designed to compare endotracheal intubation with the help of a rigid laryngoscope or a fibrescope in patients with rheumatoid arthritis.
Methods : Intubation difficulties with the laryngoscope and the fibrescope in patients with rheumatoid arthritis were investigated during a period of five and a half years. The anaesthesia records were used for analysis. The patients were divided into two groups (group I with 41 patients and group II with 37 patients) reflecting the change in the routine airway management in patients with rheumatoid arthritis in our hospital from the beginning of 1993. Before that time the patients were usually intubated orotracheally under general anaesthesia, but since 1993 rheumatoid patients with anticipated difficulties in endotracheal intubation have been preferably intubated fibreoptically awake under sedation and topical anaesthesia with a fibrescope.
Results : Major difficulties in endotracheal intubations were encountered in 13% of patients in group I and in 8% in group II. On two occasions in group I tracheostomy was needed. In one of these patients, emergency tracheostomy was performed. In the latter group, the main reason for prolonged fibreoptic intubations was lack of experience.
Conclusion : The introduction of fibreoptic intubation technique has had a favourable influence on the safety in the airway management of surgical patients with rheumatoid arthritis.     

LEARNING FIBREOPTIC INTUBATION: USE OF SIMULATORS V. TRADITIONAL TEACHING

This study compared a graduated training programme with thatof a traditional teaching method to facilitate the learningof the technique of fibreoptic nasotracheal intubation. Thirty-twoanaesthesia trainees were randomly assigned to two groups. Thegraduated programme involved: practice on a bronchoscopy teachingmodel: exposure of the epiglottis and vocal cords in patientsrecovering from general anaesthesia; performance of fibreopticnasotracheal intubation in awake sedated patients. The traditionalprogramme involved: demonstration (on a patient) of one fibreopticnasotracheal intubation by the instructor; performance of fibreopticnasotracheal intubation (by the trainee) in awake sedated patients.Nasotracheal intubation was accomplished significantly moreoften by the trainess in the graduated programme (86 out of96 (89.6%) v. 64 out of 96 (66.5%) (P < 0.01). The resultsdemonstrate that trainees who undergo a graduated training programmeusing simulators are initially more successful at awake fibreopticnasotracheal intubation than those who have learned in the traditionalmanner, and that the conditions of the investigation were acceptableto the trainees and patients.     

Failed intubation in obstetrics

Failed intubation in obstetric practice is rare, however it can have a devastating impact on the mother and fetus if not managed appropriately.Over the last 20 years there have been significant changes in anaesthetic management and training; in addition The European Working Time Directive has led to a reduction in junior doctors' hours. As a result, trainees now have less exposure to airway management, specifically endotracheal intubation.Acquiring skills in obstetric general anaesthesia is increasingly difficult as the majority of women will be suitable for regional anaesthesia.Training must be targeted at the differences between the airway in the non-pregnant and pregnant woman, and it is essential that all training opportunities in obstetric general anaesthesia should be taken. Use of simulation and animal models is an effective way of improving teamwork and confidence to deal with emergency situations such as failed intubation.     

General anaesthesia for operative obstetrics

Although the fraction of caesarean sections performed under general anaesthesia has decreased greatly over the past 40 years, the caesarean section rate has increased. Therefore, the actual number of general anaesthetics may not have declined greatly year by year. However, there is an increasing likelihood that a trainee’s first experience of caesarean section under general anaesthesia will be an emergency case. Mortality associated with general anaesthesia for caesarean section is virtually confined to emergency cases; airway problems predominate. Cord prolapse and placenta praevia are not absolute contraindications to general anaesthesia. A scarred uterus (e.g. after previous caesarean section) is a key predictor of intraoperative major haemorrhage. Accurate and timely multidisciplinary communication is vital during general anaesthesia for obstetrics. Avoidance of aortocaval compression (by left-lateral tilt) is of paramount importance for maintenance of feto-placental perfusion. At induction of general anaesthesia, head-up tilt is recommended as routine, both for prevention of regurgitation and for optimization of preoxygenation and airway management. Gas monitoring lends objectivity to preoxygenation: the endpoint is an end-tidal fractional expired oxygen concentration approaching 90%. Thiopental is the induction agent of choice. In pre-eclampsia, it is vital that the pressor response to intubation is obtunded to prevent intracerebral haemorrhage. The opioids alfentanil and remifentanil are suitable adjuncts to thiopental. 0.75 minimum alveolar concentration end-tidal vapour concentration (plus 50% nitrous oxide) is required for a bispectral index of less than 60. There is no rationale for risking awareness with light anaesthetic regimens. Rocuronium is an acceptable (and licensed) alternative to succinylcholine for caesarean section. Training opportunities in obstetric general anaesthesia (particularly elective cases) should be encouraged.     

Anaesthesia trainees' exposure to regional anaesthesia in an Australian tertiary adult teaching hospital

The purpose of this study was to quantify the exposure of anaesthetic trainees to regional anaesthesia in an Australian tertiary adult teaching hospital. We reviewed data collected on all regional blocks performed by the anaesthetic department over a two-year period. The data was then broken down to give an estimate of the number of each block performed by each training year group. There was an average of 27.7 full-time equivalent trainees attached to the department. Trainees performed a total of 1374 blocks over this period. The average number of blocks performed by basic training year one trainees each year was 6.5, basic training year two trainees 13.5, advanced training year one trainees 14.9, advanced training year two trainees 19.1, advanced training year three trainees 23.1 and regional fellows 144.0. The number of total blocks and the proportion of advanced blocks increased with increasing level of training while supervision declined. Trainees in the two regional fellowship positions (7% of the trainee pool) performed 42% of the 1374 blocks. Factors that may influence the exposure of trainees to regional anaesthesia and the assessment of competency are considered.     

Defining and developing expertise in tracheal intubation using a GlideScope® for anaesthetists with expertise in Macintosh direct laryngoscopy: an in‐vivo longitudinal study

Although videolaryngoscopy can provide excellent views of the laryngeal structures as both the primary method of tracheal intubation and as a rescue technique for difficult direct laryngoscopy, the existing literature is inadequate to define expertise or even competence. We observed the performance of nine trainees during 890 intubations, with an additional 72 intubations performed by expert anaesthetists used as a control group. Univariate and multivariate mixed‐effects logistic regression models were applied to detect potential predictors of successful intubation and define the number of intubations necessary for a trainee to achieve expertise (> 90% probability of optimal performance). Optimal performance was predicted by single laryngoscope insertion (p < 0.001) and a Cormack and Lehane grade‐1 view (p < 0.001), and not by normal lifting force applied to the device (p = 0.15), with expertise reached after 76 attempts. These results indicate that expertise in videolaryngoscopy requires prolonged training and practice.     

Perception of training needs and opportunities in advanced airway skills: a survey of British and Irish trainees

BACKGROUND AND OBJECTIVE: We surveyed delegates at the Group of Anaesthetists in Training (UK) meeting to investigate evidence of a training-gap (number of fibreoptic intubations believed to bestow competence vs. number actually performed). METHODS: Questionnaires were distributed to and collected from delegates in person. Questions covered six areas, including experience of fibreoptic intubation and cricothyrotomy, fibreoptic intubation as a specialist skill and ethical issues. RESULTS: We received 221 replies (76%). All trainees believed competence to be achievable with 10 intubations (interquartile range (IQR) 10-20); the median number performed was 2 (IQR 0-4). This was statistically significant for the groups' senior house officers, 1st and 2nd year registrars and 3rd and 4th year registrars; P < 0.0001. Many final year trainees (12/20, 60%) also failed to achieve their competency target. Few trainees had seen or performed any cricothyrotomies (medians 0, IQRs 0-1 and 0-0). Most (195/208, 94%) believed that fibreoptic intubation was a core skill and 199/212 (94%) believed that all should be competent by completion of training. Ten percent (n = 208) felt it unethical to perform an awake training intubation with full consent and 10% believed it acceptable without explanation. Most (82.7%) would fibreoptically intubate an asleep patient (requiring intubation) without consent. CONCLUSION: Trainees reported a gap between their perception of competence and achievement in awake fibreoptic intubation. Simple and complex simulations and structured training programmes may help. Anaesthetists must address the ethics of clinical training in advanced airway management.     

Validation of a simple algorithm for tracheal intubation: daily practice is the key to success in emergencies--an analysis of 13,248 intubations

A fundamental skill of the anesthesiologist is airway management. We validated a simple endotracheal intubation algorithm with a large proportion of fiberoptic tracheal intubations used for years in daily practice. Over 2 yr, 13,248 intubations (>90% of all intubations, including obstetrics and ear, nose, and throat patients) in a heterogeneous patient population at our acute care hospital were evaluated prospectively. About 80 physician and nurse anesthetists were involved. Once the indication for intubation (oral or nasal) was established, the first step was to choose between the primary conventional technique (laryngoscope with Macintosh blades) and the primary fiberoptic technique. For the conventional technique, a well defined procedure had to be followed (maximum of two attempts at intubation; if unsuccessful, switch to secondary oral fiberoptic intubation). For the primary fiberoptic technique, the anesthesiologist had to decide between nasotracheal intubation in awake patients and oral intubation in anesthetized patients. Fiberoptics were used for 13.5% of the intubations. By following our algorithm, intubation failed in 6 out of 13,248 cases (0.045%; 95% confidence interval 0.02%-0.11%). We demonstrate that a simple algorithm for endotracheal intubation, basically limited to fiberoptics as the only aid, is successful in daily practice. Only methods that are practiced daily can be used successfully in emergencies.     

Accuracy and reliability of the self-inflating bulb to verify tracheal intubation in out-of-hospital cardiac arrest patients

BACKGROUND: To determine the sensitivity and specificity of the self-inflating bulb (SIB) to verify tracheal intubation in out-of-hospital cardiac arrest patients. METHODS: Sixty-five consecutive adult patients with out-of-hospital cardiac arrest were enrolled. Patients were provided chest compression and ventilation by either ba-valve-mask or the esophageal tracheal double-lumen airway by ambulance crews when they arrived at the authors' department. Immediately after intubation in the emergency department, the endotracheal tube position was tested by the SIB and end-tidal carbon dioxide (ETCO2) monitor using an infrared carbon dioxide analyzer. We observed the SIB reinflating for 10 s, and full reinflation within 4 s was defined as a positive result (tracheal intubation). RESULTS: Five esophageal intubations occurred, and the SIB correctly identified all esophageal intubations. Of the 65 tracheal intubations, the SIB correctly identified 47 tubes placed in the trachea (72.3%). Delayed but full reinflation occurred in one tracheal intubation during the 10-s observation period. Fifteen tracheal intubations had incomplete reinflation during the observation period, and two tracheal intubations did not achieve any reinflation. Thirty-nine tracheal intubations were identified by ETCO2 (60%). When the SIB test is combined with the ETCO2 detection, 59 tracheal intubations were identified with a 90.8% sensitivity. CONCLUSIONS: The authors found a high incidence of false-negative results of the SIB in out-of-hospital cardiac arrest patients. Because no single test for verifying endotracheal tube position is reliable, all available modalities should be tested and used in conjunction with proper clinical judgment to verify tracheal intubation in cases of out-of-hospital cardiac arrest.     

Laryngoscopic intubation: learning and performance

BACKGROUND: Many healthcare professionals are trained in direct laryngoscopic tracheal intubation (LEI), which is a potentially lifesaving procedure. This study attempts to determine the number of successful LEI exposures required during training to assure competent performance, with special emphasis on defining competence itself. METHODS: Analyses were based on a longitudinal study of novices under training conditions in the operating room. The progress of 438 LEIs performed by the 20 nonanesthesia trainees was monitored by observation and videotape analysis. Eighteen additional LEIs were performed by experienced anesthesiologists to define the standard. A generalized linear, mixed-modelling approach was used to identify key aspects of effective training and performance. The number of tracheal intubations that the trainees were required to perform before acquiring expertise in LEI was estimated. RESULTS: Subjects performed between 18 and 35 laryngoscopic intubations. However, statistical modeling indicates that a 90% probability of a "good intubation" required 47 attempts. Proper insertion and lifting of the laryngoscope were crucial to "good" or "competent" performance of LEI. Traditional features, such as proper head and neck positions, were found to be less important under the study conditions. CONCLUSIONS: This study determined that traditional LEI teaching for nonanesthesia personnel using manikin alone is inadequate. A reevaluation of current standards in LEI teaching for nonanesthesia is required.     

Learning fibreoptic endoscopy. Nasotracheal or orotracheal intubations first?

We have studied the extent to which learning fibreoptic nasotracheal endoscopy first helped anaesthetists to learn fibreoptic orotracheal endoscopy later, and vice versa. After preliminary training on a bronchial tree model, 30 anaesthetic trainees were randomly allocated to the nasal first/oral second group, who performed 10 nasal intubations followed by 10 oral intubations, or the oral first/nasal second group, who performed 10 oral intubations followed by 10 nasal intubations, in anaesthetised, ASA group I or II patients undergoing elective oral or general surgery. Each type of endoscopy was taught in a standard manner, with the aid of an endoscopic video-camera system, under the supervision of experienced instructors. Performing nasal endoscopy second (average 70.8 s) took significantly less time than performing it first (average 84.4 s) and performing oral endoscopy second (average 35.2 s) took significantly less time than performing it first (average 48.5 s). The mean (SD) total endoscopy time for all the endoscopies (both nasal and oral) in the nasal first/oral second group [1196 (162) s] was not significantly different from that for all the endoscopies in the oral first/nasal second group [1193 (188) s]. Because there is no advantage or disadvantage to be gained in starting to learn either type of endoscopy first, graduated training programmes can be planned according to the availability of suitable patients for fibreoptic intubation, without instructors needing to consider whether trainees make better progress if they learn one technique before the other.