Learning Curve of Fiberoptic Bronchoscope-guided Tracheal Intubation Through Supraglottic Airway Device for Pediatric Airway Management: a Manikin Study

Overview

Journal Korean J Anesthesiol

Specialty Anesthesiology

Date 2023 Mar 20

PMID 36935387

Authors

Sang-Hwan Ji

Sung-Ae Cho

Young-Eun Jang

Eun-Hee Kim

Jin-Tae Kim

Hee-Soo Kim

Ji-Hyun Lee

Affiliations

Soon will be listed here.

Abstract

Background: Although fiberoptic-guided endotracheal intubation using a supraglottic airway device (SAD) is a good alternative for the management of difficult airways, its learning curve for residents has not been evaluated in pediatric patients. We aimed to train residents using a pediatric manikin and obtain learning curves to evaluate the efficiency of the training.

Methods: We conducted a single-armed prospective study with anesthesiology residents. Plain endotracheal tube (ETT) intubation guided by a fiberoptic bronchoscope through Ambu® AuraGainTM was demonstrated in a pediatric manikin to the participants before training. The procedure was divided into four steps: SAD insertion, vocal cord identification, carina identification, and ETT insertion into the trachea. The results and elapsed procedure times of each trial were recorded. The learning curves for the participants were constructed and analyzed using the cumulative sum method.

Results: All the 30 participants acquired proficiency at the end of practice between eight and 25 trials. The overall success rate for the procedure was 92.8%, and above 80% for all participants. Mean ± standard deviation procedure time was 71.3 ± 50.7 s. The 4th step accounted for 86.2% and 48.0% of the total failures and procedure time, respectively. The procedure time rapidly decreased in the 2nd trial; a modest decline was observed thereafter.

Conclusions: Trainees can obtain proficiency for fiberoptic-guided intubation through SAD within 25 times when using pediatric manikin. Effect of the training on performance in actual clinical situation should be studied.

References

Ogrinc G, Armstrong G, Dolansky M, Singh M, Davies L . SQUIRE-EDU (Standards for QUality Improvement Reporting Excellence in Education): Publication Guidelines for Educational Improvement. Acad Med. 2019; 94(10):1461-1470. PMC: 6760810. DOI: 10.1097/ACM.0000000000002750. View

Kestin I . A statistical approach to measuring the competence of anaesthetic trainees at practical procedures. Br J Anaesth. 1995; 75(6):805-9. DOI: 10.1093/bja/75.6.805. View

Asai T, Shingu K . Difficulty in advancing a tracheal tube over a fibreoptic bronchoscope: incidence, causes and solutions. Br J Anaesth. 2004; 92(6):870-81. DOI: 10.1093/bja/aeh136. View

de Oliveira Filho G, Helayel P, da Conceicao D, Garzel I, Pavei P, Sperotto Ceccon M . Learning curves and mathematical models for interventional ultrasound basic skills. Anesth Analg. 2008; 106(2):568-73, table of contents. DOI: 10.1213/ane.0b013e3181605412. View

Kristensen M . The Parker Flex-Tip tube versus a standard tube for fiberoptic orotracheal intubation: a randomized double-blind study. Anesthesiology. 2003; 98(2):354-8. DOI: 10.1097/00000542-200302000-00014. View

Brimacombe J, Berry A . A proposed fiber-optic scoring system to standardize the assessment of laryngeal mask airway position. Anesth Analg. 1993; 76(2):457. View

Kovatsis P . Continuous ventilation during flexible fiberscopic-assisted intubation via supraglottic airways. Paediatr Anaesth. 2016; 26(4):457-8. DOI: 10.1111/pan.12863. View

Hunyady A, Polaner D . Pediatric airway management education and training. Paediatr Anaesth. 2019; 30(3):362-370. DOI: 10.1111/pan.13808. View

Gasteiger L, Oswald E, Keplinger M, Putzer G, Luger M, Neururer S . A randomized trial comparing the Ambu® Aura-i™ and the Ambu® Aura Gain™ laryngeal mask as conduit for tracheal intubation in children. Minerva Anestesiol. 2020; 86(11):1143-1150. DOI: 10.23736/S0375-9393.20.14422-5. View

10.

Stein M, Park R, Kovatsis P . Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth. 2020; 30(3):269-279. DOI: 10.1111/pan.13814. View

11.

Kim H, Park H, Kim S, Ro Y, Yang H, Koh W . A Randomized Controlled Trial Comparing Ambu AuraGain and i-gel in Young Pediatric Patients. J Clin Med. 2019; 8(8). PMC: 6723277. DOI: 10.3390/jcm8081235. View

12.

Brull S, Wiklund R, Ferris C, Connelly N, Ehrenwerth J, Silverman D . Facilitation of fiberoptic orotracheal intubation with a flexible tracheal tube. Anesth Analg. 1994; 78(4):746-8. DOI: 10.1213/00000539-199404000-00022. View

13.

Lee J, Park S, Jang Y, Kim E, Kim H, Kim J . The distance between the glottis and the cuff of a tracheal tube placed through three supraglottic airway devices in children: A randomised controlled trial. Eur J Anaesthesiol. 2019; 36(10):721-727. DOI: 10.1097/EJA.0000000000001070. View

14.

Black A, Flynn P, Smith H, Thomas M, Wilkinson K . Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015; 25(4):346-62. DOI: 10.1111/pan.12615. View

15.

Omar S, Hardy Mohamad Zaini R, Wong T, Hassan W . Comparison of the Air-Q intubating laryngeal mask airway and the Ambu AuraGain laryngeal mask airway as a conduit for fibreoptic assisted endotracheal intubation for simulated cervical spine injury. Anaesthesiol Intensive Ther. 2021; 53(3):241-245. PMC: 10165333. DOI: 10.5114/ait.2021.105759. View

16.

Orhan-Sungur M, Altun D, Ozkan-Seyhan T, Aygun E, Koltka K, Camci E . Learning curve of ultrasound measurement of subglottic diameter for endotracheal tube selection in pediatric patients. Paediatr Anaesth. 2019; 29(12):1194-1200. DOI: 10.1111/pan.13751. View

17.

Altun D, Ozkan-Seyhan T, Camci E, Sivrikoz N, Orhan-Sungur M . Learning Curves for Two Fiberscopes in Simulated Difficult Airway Scenario With Cumulative Sum Method. Simul Healthc. 2019; 14(3):163-168. DOI: 10.1097/SIH.0000000000000368. View

18.

Moser B, Keller C, Audige L, Dave M, Bruppacher H . Fiberoptic intubation of severely obese patients through supraglottic airway: A prospective, randomized trial of the Ambu AuraGain™ laryngeal mask vs the i-gel™ airway. Acta Anaesthesiol Scand. 2018; 63(2):187-194. DOI: 10.1111/aas.13242. View

19.

Jagannathan N, Roth A, Sohn L, Pak T, Amin S, Suresh S . The new air-Q intubating laryngeal airway for tracheal intubation in children with anticipated difficult airway: a case series. Paediatr Anaesth. 2009; 19(6):618-22. DOI: 10.1111/j.1460-9592.2009.02990.x. View

20.

Lee J, Nam S, Jang Y, Kim E, Kim H, Kim J . Clinical performance of Ambu AuraGain versus i-gel in anesthetized children: a prospective, randomized controlled trial. Anesth Pain Med (Seoul). 2020; 15(2):173-180. PMC: 7713828. DOI: 10.17085/apm.2020.15.2.173. View