Today on the podcast, we discuss how to learn and teach laryngoscopy and intubation. There have been tangential discussions on EMCrit in the past:
- EMCrit 300 Airway Continuous Quality Improvement and the Resus Airway Bundle
- EMCrit 233 EMCrit Failed Airway Algorithm
- EMCrit 253 Kovacs Kata to Optimize a Failing Laryngoscopy Attempt
Learning Curve
Equipment Choices
Video first, last, and always!
Additional Advantages to Video-Always
- Allows Team Suctioning
- Allows ELM
- Allows Kovacs Kata seamlessly
- Allows self-review
- Allows learner teaching
- Allows Program Review
- Allows Superior Human Factors
Video Choices
SG Video as a direct blade
SG Video Looking at the Screen
Driver's Recs
from Driver – How to Learn Laryngoscopy
Novices (eg, inexperienced resident physicians, medical students) more quickly achieve higher success when using a video laryngoscope but, less intuitively, novices also have better eventual success with direct laryngoscopy when they learn intubation using a standard geometry video laryngoscope while viewing the screen, compared to a non-video direct laryngoscope. 25-31 The reasons for this are threefold. First, they can receive detailed real-time feedback as opposed to general advice. Second, the magnified view of the airway shows anatomic detail not visible by direct vision. Third, the intubator gains detailed knowledge of how the laryngeal view is altered with manipulations of blade position, angle, or force on specific anatomic structures. This suggests an optimal path for novice intubators: use a standard geometry video laryngoscope while viewing the screen until proficiency is attained.
25. Sakles JC, Mosier J, Chiu S, Cosentino M, Kalin L. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Ann Emerg Med. 2012;60:739-748.
26. 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;101:568-572.
27. Monette DL, Brown CA III, Benoit JL, et al. The impact of video laryngoscopy on the clinical learning environment of emergency medicine residents: a report of 14,313 intubations. AEM Educ Train. 2019;3:156-162.
28. Herbstreit F, Fassbender P, Haberl H, Kehren C, Peters J. Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students. Anesth Analg. 2011;113:586-590.
29. 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.
30. Sainsbury JE, Telgarsky B, Parotto M, Niazi A, Wong DT, Cooper RM. The effect of verbal and video feedback on learning direct laryngoscopy among novice laryngoscopists: a randomized pilot study. Can J Anaesth. 2017;64:252-259.
31. O’Shea JE, Thio M, Kamlin CO, et al. Videolaryngoscopy to teach neonatal intubation: a randomized trial. Pediatrics. 2015;136:912-919
- Bougie
- How to Learn Styleted Tube Placement
- How to Learn HA
- How to Learn HA Tube Placement
VL Choices
Good lighting, matched blade shape, screen view matches direct view
Blade Size
3 vs. 4
- Just published: Retrospective Trial Shows Lower Success and Worse Glottic View with Mac 4 compared to Mac 3 [
- PMID: 35974189
- PMID: 36895888
- 10.1097/00000542-200606000-00006
- 10.1016/j.ajem.2017.09.050
Set-Up
- All difficult airway equipment
- Checklist
- Items on the table
- Supervisor in a position to take over
- Recitation of the Plan
- Learner then experienced intubator
The Attempt
Press Record or use a student with a phone
Suction in your Hand
Midline
Incrementalization/Stay Choppy
Say the structures out loud
- Uvuloscopy
- Epiglottoscopy
- Valeculloscopy
- Glottoscopy
Avoid success with bad technique
How to Coach during the Intubation RCT
- https://doi.org/10.1002/aet2.10846
After the Intubation
the 2nd intubation
Please, please teach proper sedation/analgesia and the post-intubation package
Debrief
with video review
Additional Literature
- EM Residents performed as well as anesthesia residents for trauma airway [14707940]
- Airway success was the same in trauma when performed by EM or Anesthesia [14709430]
- Another one comparing supervision by EM and Anesthesia demonstrating no difference [23473818]
- Sakles et al. showed little improvement over the course of 3 years of EM residency with DL, but sig. increase each year with Glidescope [25493156]
- Maintenance of basic endotracheal intubation skills with direct or video-assisted laryngoscopy: A randomized crossover follow-up study in inexperienced operators [34522831]
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Great Episode Scott— lots of great stuff here!!! A few comments: 1. Not only do I totally agree re: novices learning by using standard geometry video *looking at the screen* but will take it a step further and say that even just watching a series of well done methodical/incremental landmark intubations is incredibly insightful. I think there’s even a ton of value there and it’s why I’ve tweeted out many of the good ones— especially the ones with a specific teaching point. 2. Regarding the Midline approach: Crazy thing about this is I’ve always done midline because this was the… Read more »
All of your airway podcasts and videos have been very informative, and they have helped me improve my patient care. I will also share this information with my colleagues. Thank you so much!
-Pri
Scott, so many great tips in here. I 100% agree with everything you said, stay midline, use video standard geometry with bougie for learners, expand out from there to hyperangulated blade, etc. I was teaching the Airway station in ATLS this week and found myself begging for a video scope so I could do better coaching. Something I would add is the idea of incrementally increasing the complexity not just of the airway being managed but of the situation being managed, and a way to think about that and a proposed way of teaching it. My friend and colleague Chris… Read more »
Hi Dr. Weingart, Thank you so much for this episode. I appreciated the rec to perform a second intubation. I read about that on UpToDate and thought it was an interesting approach but haven’t seen in practiced yet by any clinicians I’ve rotated with. I’m hopeful to find a mentor who can help me get comfortable with this technique – it seems much better for patients.