Difficult Airway Simulation-based Training
Condition: Intubation; Difficult or Failed; Educational Problems; Critical Illness
MeSH terms: Critical Illness
Study type: Observational

Summary: 
      Difficult airways remain a significant problem in anaesthesia, intensive care and emergency
      medicine. Simulation-based training gives better outcomes compared to non-simulation and
      non-intervention education. However, it remains unclear how long the acquired skills are
      retained and how often simulation training should repeat. The study aimed to investigate the
      efficacy and skills retention in training for difficult airway management in
      anaesthesiologists. After ethical committee approval, we conducted a prospective control
      study at the postgraduate Department of Surgery, Anaesthesiology and Intensive Therapy
      (Bogomolets National Medical University) from July to December 2022. Anaesthesiologists who
      applied for the continuous medical education course "Difficult airways management" were
      involved in the study. The simulation room included a mannequin Laerdal SimMom Advanced
      Patient Simulator, vital monitor, anaesthesia station LEON and airway devices. Each volunteer
      went through two simulation scenarios of difficult airway management: 1) "cannot intubate,
      can ventilate" (CI), 2) "cannot intubate, cannot ventilate" (CICV) with the assistance of the
      training centre operator. The primary endpoints included: more than three laryngoscopy
      attempts; supraglottic airway attempt missing; call for help skip; failure to initiate a
      surgical airway (for the CICV scenario). Secondary endpoints included: time to call for help;
      mean duration of desaturation; use of bougie; use of video laryngoscope (Airtraq); mean
      number of intubation attempts; improper usage of equipment of equipment, time to initiation
      of surgical airway preparation; time to initiation of surgical airway ventilation.
    

Detailed description: 
      After ethical committee approval, we conducted a prospective control study at the
      postgraduate Department of Surgery, Anaesthesiology and Intensive Therapy (Bogomolets
      National Medical University) from July to December 2022. Anaesthesiologists who applied for
      the continuous medical education course "Difficult airways management" were involved in the
      study. We obtained consent from them to participate anonymously as volunteers. Before the
      first training, we interviewed all participants about their experience in working in the
      speciality, difficult airways management, learning at any simulation training and difficult
      airways training particularly.

      The simulation room included a mannequin Laerdal SimMom Advanced Patient Simulator, vital
      monitor, anaesthesia station LEON and airway devices. Standard settings included modelling of
      tongue oedema to grade 4 visualizations on laryngoscopy according to the Cormack and Lehane
      classification, as well as additional pharyngeal obstruction and stiffness of both lungs for
      the "cannot ventilate" scenario. A standard set of tools and equipment for ensuring airway
      patency, ventilation and tracheal intubation included facemasks, oropharyngeal and nasal
      airways, laryngoscopes, laryngeal masks, and tracheal tubes in a range of sizes. The trolley
      for difficult airways was available for each station and was equipped with additional
      laryngoscope blades of various sizes, a video laryngoscope, laryngeal masks of various sizes
      (Igel), introducers for tracheal tubes (stylets and bougies), Airtraq, a cricotomy kit.

      Monitoring provided SpO2, EtCO2, ECG and non-invasive blood pressure measurement. When the
      oxygen delivery was interrupted for 20 seconds or more, the SpO2 gradually decreased by 3%
      every 5 seconds and reached 90% after 20 seconds. A value of SpO2 < 90% was considered
      desaturation. Effective ventilation was defined after at least two effective breaths
      evidenced by an EtCO2 curve on the monitor.

      Each volunteer went through two simulation scenarios of difficult airway management: 1)
      "cannot intubate, can ventilate" (CI), 2) "cannot intubate, cannot ventilate" (CICV) with the
      assistance of the training centre operator. Participants were expected to follow an algorithm
      according to the Difficult Airway Society (DAS) recommendations [4].

      During the scenario, we recorded significant deviations from the DAS protocol and other
      indicators that impacted the quality of the algorithm execution. The primary endpoints
      included significant deviations from the DAS protocol: more than three laryngoscopy attempts;
      supraglottic airway attempt missing; call for help skip; failure to initiate a surgical
      airway (for the CICV scenario). Secondary endpoints included: time to call for help; mean
      duration of desaturation; use of bougie; use of video laryngoscope (Airtraq); mean number of
      intubation attempts; improper usage of equipment of equipment, time to initiation of surgical
      airway preparation; time to initiation of surgical airway ventilation Following the first
      simulation round, volunteers were trained on the same day in difficult airway management
      according to DAS guidelines, using the same equipment as during the simulation. The
      participants repeated the simulation scenarios immediately after the training and six months
      later. The primary and secondary endpoints were compared between three rounds: initial
      simulation (Group 1), immediately after training (Group 2), and six months after training
      (Group 3).

      Statistical analysis was performed using licensed Microsoft Office Excel and web source
      www.socscistatistics.com. We used Student's, Kruskal-Wallis and Fisher's exact tests. The
      difference was considered significant at α < 5% (p < 0.05).
    

Intervention name(s): Simulation training
Intervention type(s): Behavioral
Intervention description(s): Each volunteer went through two simulation scenarios of difficult airway management: 1) "cannot intubate, can ventilate" (CI), 2) "cannot intubate, cannot ventilate" (CICV) with the assistance of the training centre operator. Following the first simulation round, volunteers were trained on the same day in difficult airway management according to DAS guidelines, using the same equipment as during the simulation. The participants repeated the simulation scenarios immediately after the training and six months later.
Observational model: Cohort
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        Adult anesthesiologists volunteers
      
Keywords: difficult airways; simulation training