Simulator Training Improves Fiber-optic Intubation Proficiency among Emergency Medicine Residents
Funding Sources: HealthPartners Institute for Medical Education.
Address for correspondence and reprints: Emily Binstadt, MD: firstname.lastname@example.org.
Objectives: The objective was to observe how a workshop using a virtual reality bronchoscopy simulator and computer-based tutorial affects emergency medicine (EM) resident skill in fiber-optic intubation.
Methods: In this observational before-and-after study, EM resident performance on three simulated pediatric difficult airway cases was observed before and after a short computer-based tutorial and 10 minutes of self-directed practice. The primary outcome was the total time required to place the endotracheal tube (ETT), secondary outcomes included the number of endoscope collisions with mucosa, and a calculated efficiency score measuring the proportion of time participants spent looking at correct central airway structures. Nonparametric Wilcoxon signed rank tests compared performance on the first versus the repeat attempt for each of the three simulated cases. Participants were surveyed regarding their assessments of the experience.
Results: Significant decreases in median procedure times and number of scope collisions and increases in median efficiency scores were seen for Cases 1 and 2. Case 3 showed no significant changes in outcomes between first and repeat attempts. Participants positively assessed the training and felt that its use would improve clinical practice.
Conclusions: Participation in a simulation-based fiber-optic intubation skill workshop can improve fiber-optic intubation performance rapidly among EM residents. Future research should evaluate if this enhanced performance translates to improved clinical performance in the emergency department (ED).
In the emergency department (ED), fiber-optic intubation (FOI) is an alternative to blind nasotracheal intubation or direct laryngoscopy and is especially useful when the intubation is likely to be challenging due to swollen or distorted airways.
Teaching FOI skills to novices is challenging.1 Training on patients may expose patients to increased risks of oxygen desaturation or airway trauma.2,3 Preserved cadavers have limitations due to reduced tissue mobility. Simulated airways are advantageous because they can be configured to offer varying degrees of difficulty, unlike human airways.3
Training programs face pressure to provide adequate experiences with advanced airway devices;4 thus, several different anatomic5 and nonanatomic1 FOI models have been used, including computer-based simulations6 and model-based teaching on simulated airways. Simulated airway training for FOI has proven more effective than didactic teaching methods, and simulation training appears to translate to improvements in clinical performance.7,8
Prior studies have demonstrated that use of the AccuTouch endoscopy simulator (Immersion Medical, Inc., Gaithersburg, MD) improves psychomotor skills and clinical performance parameters for FOI. Specifically, novice pediatrics residents improved time to endotracheal tube (ETT) placement and reduced the number of collisions with the mucosa after less than 1 hour of simulator training.9 After 4 days of training using the simulator, novice anesthesiology residents approximated expert-level proficiency in time to fiber-optic ETT placement in normal adult cadaveric airways.10
Although clinical practice has been the traditional method of teaching FOI proficiency, simulation-based learning may offer practical advantages to learners, making this rarely encountered clinical procedure more familiar and thus more useful. We hypothesized that 1 hour of practice using a virtual reality simulator would improve emergency medicine (EM) residents’ performance of and comfort with the procedure.
The study used an observational before-and-after design. Data were collected from performance on six simulated FOI cases and from presession and postsession surveys. Institutional review board (IRB) approval was obtained through the HealthPartners Research Foundation IRB.
Study Setting and Population
Our study took place at the HealthPartners Simulation Center for Patient Safety at Metropolitan State University in St. Paul, MN (http://www.hpsimcenter.com/) using the AccuTouch endoscopy simulator. Study participants were EM residents who volunteered from the HealthPartners Institute for Medical Education/Regions Hospital Emergency Medicine Residency located in St. Paul, Minnesota.
Each resident completed an anonymous 5-item questionnaire before the workshop, reporting any formal training in bronchoscopy and whether they had ever used a bronchoscope to perform bronchoscopy, laryngoscopy, or intubation. Each participant then completed the following during the educational workshop:
- 1Performed three preprogrammed simulated bronchoscopy cases in the same order. The pediatric difficult airways cases were selected from software included with the bronchoscopy simulator.
- 2Reviewed 20-minute on-screen text and video tutorial detailing how to hold and drive the bronchoscope, apply topical analgesia, and traverse the vocal cords and describing complications of bronchoscopy. The tutorial reviewed an entire fiber-optic bronchoscopy on an awake but sedated patient. Upon completion of the tutorial, participants were allowed 10 minutes of practice using any of the three preprogrammed cases.
- 3Repeated the same three simulated bronchoscopy cases in the same order.
Case 1 simulated a 5-year-old child with an inflamed mass in the upper airway. Case 2 simulated a neonate with achondroplasia, narrow nasal anatomy, and a slightly swollen glottis. Case 3 simulated a neonate with Pierre Robin syndrome with limited mouth opening, small mandible, asymmetric and abnormal airway anatomy, and minimal vocal cord swelling.
Following the workshop, a second anonymous survey assessed comfort with FOI, likelihood of future use, benefit of learning fiber-optic techniques, and utility of simulation-based training using a 5-point Likert scale.
The study’s primary outcome was time to intubation, measured from insertion of scope until successful ETT placement. Secondary outcomes were the number of endoscope collisions with the mucosa, and an efficiency score calculated from the ratio of time spent viewing central airway structures versus peripheral mucosal wall. All data were collected automatically by the simulator.
Nonparametric Wilcoxon signed rank tests performed at the 5% level compared initial and repeat performance for the continuous outcomes of time to intubation, endoscope collisions, and calculated efficiency score. Descriptive statistics were used for the survey data.
Twenty-one EM residents participated and completed both the pre- and postworkshop surveys. Only 2 reported any formal training in bronchoscopy; however, most reported hands-on experience with a bronchoscope. Thirteen had performed a bronchoscopy and 7 had performed a fiber-optic laryngoscopy, but only 1 had ever completed an FOI. Participants felt the workshop improved their comfort with performing FOI (11 strongly agreed, 9 agreed, 1 no response), and all would consider using the procedure clinically (7 strongly agreed, 14 agreed). Similarly, respondents felt that learning fiber-optic techniques was a useful advanced airway management skill (19 strongly agreed, 2 agreed) and that the simulation-based training was beneficial in learning this technique (16 strongly agreed, 5 agreed).
Table 1 displays performance data for each of the simulation cases. When comparing performance parameters for Case 1 on initial and repeat attempts, the median procedure time and median number of scope collisions decreased, and median efficiency scores increased. Performance on Case 2 mirrors that of Case 1. In contrast, no significant changes in any of the study outcomes occurred in Case 3.
Table 1. FOI Workshop Performance Comparisons by Case
|Procedure time (sec)|
|Efficiency score (%)*|
Teaching FOI skills in the ED is challenging because the procedure is performed rarely. Simulation offers an alternative to the clinical environment as a means to practice FOI.
Performance on Case 3 was not consistent with Cases 1 and 2. During the course of the training, a technical “glitch” occurred during Case 3: the visualized posterior oropharynx suddenly moved out of sync with the participants’ movements. If participants did not move the scope during this brief period, the correct image reappeared. This may have disrupted participants and influenced the data from this case. Other explanations for the inconsistent performance on Case 3 are that participants learned skills during the first two initial cases that they applied to the third case or that Case 3 involved an easier intubation. However, if Case 3 were intrinsically easier to manage, one would expect to see a reduction in median times on the repeat attempt.
Participants demonstrated improved avoidance of airway trauma (as measured by scope collisions and efficiency scores) when comparing initial versus repeat attempts for each case. Similar to the results for intubation times, the improvement was significant for the first two cases only. Case 2 had more scope collisions on both attempts compared to other cases, likely due to the narrower and swollen airways simulated in that case.
Although our data do not support a trend towards continued progressive improvement over the six cases, both speed and efficiency improved after completion of two simulated cases (Table 1). The possibility that such a brief intervention as two hands-on, minimally supervised attempts at difficult FOI could significantly reduce subsequent procedure times and decrease airway trauma is interesting, indicating that the simulator might be an even more powerful learning tool than anticipated.
While no clear criterion standard exists, one prior study defined competence in FOI as successful completion of the procedure within 2 minutes and with 90% first-attempt success rate.10 Although the majority of participants in this study had minimal experience with FOI, all of the intubation times were less than 2 minutes. EM residents might exceed expected performance levels for novices because they have used fiber-optic equipment for other laryngeal procedures.
We directed participants to complete Cases 1 through 3 in order. If instead participants completed the three cases in different sequences, we could have determined if there was a learning effect after completing just two cases or if performance variability was due to intrinsic differences in case difficulty. To assess the impact of the educational video specifically, future studies should use a control group that does not view the video.
These data measure performance on simulated airways without validating performance with real patients. Although prior research has shown good correlation between performance on real patients and on this simulation model,10 future studies should validate this correlation among emergency physicians.
This study found that participation in a brief educational workshop using a virtual reality simulator improves the overall speed and accuracy of FOI in simulated difficult pediatric airways among EM residents. Although practice with this virtual reality simulation module may improve performance parameters on simulated airways, further studies are required to determine whether this simulator training module helps trainees achieve clinical competence in FOI of a difficult airway or improves patient outcomes. Future studies could also help define appropriate criteria to measure competence in FOI among emergency physicians.
The authors thank Debi Ryan for administrative support with this project and the HealthPartners Simulation Center Staff for providing the facilities and expertise to perform the study.