Improvement in intubation success during COVID-19 pandemic with a simple and low-cost intervention: A quasi-experimental study / Mejoría del éxito en la intubación durante la pandemia covid-19 con una intervención simple y de bajo costo: estudio cuasi-experimental

Objectives: primary objective: to improve the FPS rates after an educational intervention. Secondary objective: to describe variables related to FPS in an ED and determine which ones were related to the highest number of attempts.Design it was a prospective quasi-experimental study. Setting done in an ED in a public Hospital in Argentina. Patients there were patients of all ages with intubation in ED. Interventionsin the middle of the study, an educational intervention was done to improve FPS. Cognitive aids and pre- intubation Checklists were implemented. Main variables of interest the operator experience, the number of intubation attempts, intubation judgment, predictors of a difficult airway, Cormack score, assist devices, complications, blood pressure, heart rate, and pulse oximetry before and after intubation All the intubations were done by direct laryngoscopy (DL). Results data from 266 patients were included of which 123 belonged to the basal period and 143 belonged to the post-intervention period. FPS percentage of the pre-intervention group was 69.9% (IC95%: 60.89–77.68) whereas the post-intervention group was 85.3% (IC95%: 78.20–90.48). The difference between these groups was statistically significant (p=0.002). Factors related to the highest number of attempts were low operator experience, Cormack-Lehane 3 score and no training. Conclusions a low-cost and simple educational intervention in airway management was significantly associated with improvement in FPS, reaching the same rate of FPS than in high income countries. (AU)

Objetivos: objetivo principal: mejorar la tasa de éxito de intubación luego de una intervención educativa. Objetivo secundario: describir las variables asociadas con el éxito en el primer intento (EPI) y determinar cuáles se relacionaron con mayor número de intentos. Diseño estudio prospectivo cuasi-experimental. Ámbito: realizado en un SE de un Hospital público de Argentina. Pacientes se incluyeron todos aquellos pacientes intubados en el SE en el período de estudio. Intervención en la mitad del estudio, se realizó una intervención educativa, se implementaron ayudas cognitivas y listas de verificación preintubación. Todas las intubaciones se realizaron por laringoscopia directa. Variables de interés principales experiencia del operador, número de intentos de intubación, criterios de intubación, predictores de vía aérea difícil, grado de Cormack, dispositivos facilitadores utilizados, complicaciones y los signos vitales antes y después de la intubación. Resultados se incluyeron datos de 266 pacientes de los cuales 123 pertenecían al período basal y 143al período postintervención. El porcentaje de éxito del grupo preintervención fue del 69,9% (IC95%: 60,89-77,68) mientras que el grupo postintervención fue del 85,3% (IC95%: 78,20-90,48). La diferencia entre estos grupos fue estadísticamente significativa (p=0,002). Los factores relacionados con el mayor número de intentos fueron la baja experiencia del operador, el grado de Cormack-Lehane 3 y la falta de capacitación. Conclusiones una intervención educativa simple y de bajo costo en el manejo de la vía aérea se asoció significativamente con la mejora en el éxito del primer intento de intubación, alcanzando los porcentajes de los países de altos ingresos. (AU)

Improvement in intubation success during COVID-19 pandemic with a simple and low-cost intervention: A quasi-experimental study.

OBJECTIVES: primary objective: to improve the FPS rates after an educational intervention. SECONDARY OBJECTIVE: to describe variables related to FPS in an ED and determine which ones were related to the highest number of attempts. DESIGN: it was a prospective quasi-experimental study. SETTING: done in an ED in a public Hospital in Argentina. PATIENTS: there were patients of all ages with intubation in ED. INTERVENTIONS: in the middle of the study, an educational intervention was done to improve FPS. Cognitive aids and pre- intubation Checklists were implemented. MAIN VARIABLES OF INTEREST: the operator experience, the number of intubation attempts, intubation judgment, predictors of a difficult airway, Cormack score, assist devices, complications, blood pressure, heart rate, and pulse oximetry before and after intubation All the intubations were done by direct laryngoscopy (DL). RESULTS: data from 266 patients were included of which 123 belonged to the basal period and 143 belonged to the post-intervention period. FPS percentage of the pre-intervention group was 69.9% (IC95%: 60.89-77.68) whereas the post-intervention group was 85.3% (IC95%: 78.20-90.48). The difference between these groups was statistically significant (p=0.002). Factors related to the highest number of attempts were low operator experience, Cormack-Lehane 3 score and no training. CONCLUSIONS: a low-cost and simple educational intervention in airway management was significantly associated with improvement in FPS, reaching the same rate of FPS than in high income countries.

Impact of a Focused Online Teaching Module on Airway Intervention: Can an Online Teaching Module Enable Knowledge Acquisition and Increased Confidence in Airway Management?

OBJECTIVE: Teaching procedural skills via digital platforms is challenging. There is a paucity of literature on the feasibility of implementing an online asynchronous web-based learning (WBL) module for endotracheal intubation in Emergency Medicine. Learners completed a pre-test questionnaire prior to reviewing the module to assess their current knowledge. After completion of the online module, another assessment on airway management competency was completed. The purpose of our pilot study was to determine the feasibility of implementing an online airway module and investigate knowledge acquisition among learners who completed it. Additionally, we compared the relationship between pre-module confidence and knowledge between various training levels of those who completed the module. METHODS: The study was IRB exempt. We conducted a quasi-experimental pre- and post-test study, where learners took a multiple-choice question-based test before watching content module, and after completion of modules, they went on to complete post-test questions. All responses were collected using Google survey and the data were collected over a period of 6 months. We performed descriptive statistics for the pre- and post-module. Frequency distribution was used for data summarization and chi-square test was used to assess the difference between variables. RESULTS: We received 366 responses in the pre-test module and 105 in post-test module. Responses were summarized into 5 broad categories which assessed knowledge about airway technique, anatomical landmarks, formulas for selecting blade size, tube size, depth of tube, and case-based scenarios. All questions showed a higher percentage of correct answers in the post-assessment compared to the pre-assessment. CONCLUSION: The results demonstrated that this WBL airway module resulted in significant knowledge acquisition, as well as increased confidence when approaching airway management. The study demonstrated that a WBL airway module is a feasible method of asynchronous education for healthcare providers in all levels of training.

Altered Airway Anatomy Course Using 3D-Printed Models for Medical Students.

OBJECTIVE: Many non-airway-trained personnel are uncomfortable managing altered airway anatomy (AAA), including tracheostomy and total laryngectomy (TL) patients. Significant morbidity and mortality have resulted from first responders' inability to stabilize the airway until expert airway providers arrive. All medical school graduates should demonstrate competency of this life-saving skill. Our hypothesis was hands-on interactive simulation using 3-dimensional (3D)-printed models would improve AAA knowledge and confidence. STUDY DESIGN: Blinded, prospective cohort study. SETTING: The Ohio State University College of Medicine. METHODS: A novel curriculum was designed to teach all third-year medical students AAA fundamentals via case-based discussions, surgical videos, and hands-on student demonstration of competency by inserting a tracheostomy and endotracheal tube through 3D-printed tracheostoma models. Pre- and postcourse 5-item Likert scale surveys and AAA knowledge assessments were administered. RESULTS: Students (n = 258) felt more comfortable with knowledge of AAA equipment (3.99 vs 1.38, P < .0001), ability to stabilize AAA patients until expert airway providers arrive (3.67 vs 1.37, P < .0001), and AAA overall (3.75 vs 1.49, P < .0001) postcourse vs precourse. AAA knowledge assessment scores improved from 34.3% precourse to 75.6% postcourse (P < .0001). Interestingly, 30.7% chose bag-mask ventilation over mouth and nose and/or transoral/transnasal intubation for a total laryngectomy patient precourse vs 5.5% postcourse (P < .0001). In total, 86.7% reported inadequate exposure to AAA in medical school and 98.4% found the course to be a valuable experience. CONCLUSION: This hands-on course significantly increases medical student knowledge and comfort managing AAA patients. The course can be expanded to various trainees and providers to further promote AAA education and ultimately improve patient safety.

A prospective observational study of video laryngoscopy-guided coaching in the pediatric intensive care unit.

BACKGROUND: There are limited data on the use of video laryngoscopy for pediatric patients outside of the operating room. AIM: Our primary aim was to evaluate whether implementation of video laryngoscopy-guided coaching for tracheal intubation is feasible with a high level of compliance and associated with a reduction in adverse tracheal intubation-associated events. METHODS: This is a pre-post observational study of video laryngoscopy implementation with standardized coaching language for tracheal intubation in a single-center, pediatric intensive care unit. The use of video laryngoscopy as a coaching device with standardized coaching language was implemented as a part of practice improvement. All patients in the pediatric intensive care unit were included between January 2016 and December 2017 who underwent primary tracheal intubation with either video laryngoscopy or direct laryngoscopy. The uptake of the implementation, sustained compliance, tracheal intubation outcomes including all adverse tracheal intubation-associated events, oxygen desaturations (<80% SpO2), and first attempt success were measured. RESULTS: Among 580 tracheal intubations, 284 (49%) were performed during the preimplementation phase, and 296 (51%) postimplementation. Compliance for the use of video laryngoscopy with standardized coaching language was high (74% postimplementation) and sustained. There were no statistically significant differences in adverse tracheal intubation-associated events between the two phases (pre- 9% vs. post- 5%, absolute difference -3%, CI95 : -8% to 1%, p = .11), oxygen desaturations <80% (pre- 13% vs. post- 13%, absolute difference 1%, CI95 : -6% to 5%, p = .75), or first attempt success (pre- 73% vs. post- 76%, absolute difference 4%, CI95 : -3% to 11%, p = .29). Supervisors were more likely to use the standardized coaching language when video laryngoscopy was used for tracheal intubation than with standard direct laryngoscopy (80% vs. 43%, absolute difference 37%, CI95 : 23% to 51%, p < .001). CONCLUSIONS: Implementation of video laryngoscopy as a supervising device with standardized coaching language was feasible with high level of adherence, yet not associated with an increased occurrence of any adverse tracheal intubation-associated events and oxygen desaturation.

Prehospital Pediatric Respiratory Distress and Airway Management Training and Education: An NAEMSP Position Statement and Resource Document.

Although pediatric airway and respiratory emergencies represent high-acuity situations, the ability of EMS clinicians to effectively manage these patients is hampered by infrequent clinical exposure and shortcomings in pediatric-specific education. Cognitive gaps in EMS clinicians' understanding of the differences between pediatric and adult airway anatomy and respiratory physiology and pathology, variability in the training provided to EMS clinicians, and decay of the psychomotor skills necessary to safely and effectively manage pediatric patients experiencing respiratory emergencies collectively pose significant threats to the quality and safety of care delivered to pediatric patients. NAEMSP recommends:Pediatric airway education should include discussion of the factors that make pediatric airway management challenging.EMS agencies should provide pediatric-specific education that addresses recognition and treatment of pediatric respiratory distress based upon pathophysiology affecting upper airways, lower airways, cardiovascular systems, or extrinsic causes of disordered breathing. Pediatric airway training should also differentiate between hypoxic and hypercapnic respiratory failure. Education should emphasize that the cognitive and psychomotor skills requisite in management of pediatric respiratory emergencies will differ across patient age groups.EMS clinicians should be provided education and training in technology-dependent children and children and youth with special health care needs.EMS clinicians should receive initial and ongoing education and training in pediatric airway and respiratory conditions that emphasizes the principle of using the least invasive most effective strategies to achieve oxygenation and ventilation.Initial and continuing pediatric-focused education should be structured to maintain EMS clinician competency in the assessment and management of pediatric airway and respiratory emergencies and should be provided on a recurring basis to mitigate the decay of EMS clinicians' knowledge and skills that occurs due to infrequent field-based clinical exposure.Integration of clinician education programs with quality management programs is essential for the development and delivery of initial and continuing education intended to help EMS clinicians attain and maintain proficiency in pediatric airway and respiratory management.

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document.

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Airway Leads and Airway Response Teams: Improving Delivery of Safer Airway Management?

Purpose of Review: Airway management remains a source of significant morbidity and mortality. This review considers recent summaries of complications and looks toward strategies to improve practice using a coordinated approach. Recent Findings: A safety gap can exist between national recommendations and local practice. A lack of attention to end tidal carbon dioxide has repeatedly contributed to airway mismanagement. Clinicians must be trained in newer airway devices (videolaryngoscopes or supraglottic airways) to use them effectively. Time must be found to teach rarely performed skills (e.g., front-of-neck access). Both larger and smaller hospitals have benefitted from an airway lead or response team, coordinating education programs, ensuring the adoption of guidelines, standardizing equipment, and recognizing the role of human factors and ergonomics. Summary: Even in the twenty-first century, the incidence of airway-related morbidity and mortality can be reduced, by an institutionally supported, coordinated approach to the whole process of airway care.

Multi-specialty knowledge on surgical a management: Implementation of an educational initiative.

PURPOSE: Deficiencies in airway management knowledge can result in harm, especially in tracheostomy patients. Our objective is to assess the degree of knowledge in different medical specialties, before and after targeted airway education. MATERIALS AND METHODS: A lecture on tracheostomy management was prepared for Otolaryngology, Anesthesia, Emergency Medicine, General Surgery, Oral and Maxillofacial Surgery (OMFS), Internal Medicine (IM), and Family Medicine (FM). Before the lecture, a 12-question quiz on surgical airway knowledge was administered, and demographics from participants collected. Immediately following the lecture, participants were asked to retake the quiz. Performance was assessed. Population baseline characteristics included, specialty, years of practice, and previous education. RESULTS: A paired t-test evaluating pre- and post-lecture results showed a 34.2% improvement for all participants (n = 168) overall (2.7 points, p < 0.001). Providers with more years of practice performed better. Otolaryngology and OMFS performed the highest on the baseline test while FM and IM performed the lowest. The providers who reported previous standardized training from the hospital system, informal instruction on the ward, or had the topic covered in their degree program performed better compared to those without previous education (ANOVA, 3.5 points, p < 0.01). Providers who underwent formal training in their degree program performed the best. A Likert scale with self-assessment of comfort with surgical airway correlated positively with the performance on the quiz. CONCLUSION: Variability in tracheostomy knowledge based on specialty and years of training exists. We demonstrate that formal education on tracheostomy and surgical airways improved quantitative measures of knowledge.