Teaching Airway

TEACHING AIRWAYSJON GATWARDSYDNEY, AUSTRALIAwww.ccam.net.au

THE LESSONThe state of playUnderstanding the airwayUnderstanding the learnerTeaching methodsEvaluation

First, lets examine how we have done things in the past. We have used the Master and Apprentice Model 3

Often we learn by trial and error. And because patient safety is always a concern, we usually get one trial before being barged aside.4

Letting them have a goFor those of you who havent seen the movie, This is Dave, a college student with no powers, experience or training, who nevertheless decides to become a super-hero, known as Kick-Ass.5

www.airwayregistry.org.au

So How does Kick-Ass do? Well he gets his ass kicked Toby Fogg airway registry at RNSH first 300 intubations. Allowed SRMO and Reg to perform laryngoscopy 88% of the time.

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58%www.airwayregistry.org.au

Novices fewer than 10 tubes 1st pass success 58%. Over 100 tubes 90%.

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16%www.airwayregistry.org.au

Overall desaturation rate 16% (to less than 93%)ED now have an RSI bundle including a credentialling system whereby trainees have to have completed 3/12 of Anaesthesia before they intubate in ED8

1 2 3 4 5 attempts BADNESS

Many papers have shown that the more attempts we have at intubation, the more complications arise, which may be life-threatening. 9

1 2 3 4 5 attempts BADNESS

1st year anaesthetic residents. Defined as 90% success rate (not needing help)11

2015 paper. 3 ED residents over 2 years. Over 100 tubes each. Learning curve cumulative summation technique. Never achieved 90% success rate12

Do we have to subject 50 to 100 patients to a high chance of a failed attempt? Can we get our trainees competent faster?13

So how do we impart our expertise to others in a way that is safer for patients?14

10%90%http://www.klassewasser.de

Experts perform skills habitually. In other words they use their subconscious mind and long-term memory. Learned behaviours and actions are governed 90% by the subconscious mind (and long-term memory) and 10% by the conscious mind (and working memory). Talented teachers are able to analyse skills and behaviours stored in their long term memory and communicate them to learners. In order to teach laryngoscopy, we need to really understand the physics, and break the process down into a series of micro-skills. We also need to understand the reasons for failure 15

There are many aspects to airway management, but as an example, lets analyse oral intubation via laryngoscopy so that we can communicate it to the novice in a way thats easy to understand16

www.youtube.com/user/KeithGreenlandwww.airwaycam.com

The two guys who have made sense of all this for me are Keith Greenland, an Aussie Anaesthetist, and Rich Levitan, as American Emergency Physician. The theme of SAMCC Gold was tribes here is an example of two tribes working towards the same goal. As an Intensivist, part of a third tribe, I have morphed their two teaching strategies into one they compliment each other beautifully and can lead to a complete understanding of direct and videolaryngoscopy. 17

GREENTAN?LEVILAND?

CURVESSTAGES

The two guys who have made sense of all this for me are Keith Greenland, an Aussie Anaesthetist, and Rich Levitan, as American Emergency Physician. The theme of SAMCC Gold was tribes here is an example of two tribes working towards the same goal. As an Intensivist, part of a third tribe, I have morphed their two teaching strategies into one they compliment each other beautifully and can lead to a complete understanding of direct and videolaryngoscopy. 19

The primary curve runs from the upper incisors, around the tongue, to the epiglottis. The laryngeal vestibule is the space between the epiglottis and the glottis and this space has its own axis, which is equivalent to the line between the primary and secondary curves. The secondary curve runs down from the glottis into the trachea. 20

1 2 3

In Levitan stage 1 we FIND THE EPIGLOTTIS. To do this we negotiate the primary curve. We then move forward to get line of sight to the glottis. In Stages 2 we deliver the tube or bougie to the glottis, by negotiating the vestibular axis.In Stage 3 we advance the tube into the trachea21

Its really important to understand the curves and how different devices and manoeuvres affect them. On our airway course, we teach this using an artists curve ruler. This makes curve theory easy to understand and teaches how Stage 1 influences stage 2 and 3, and why angulated devices require an angulated bougie or stylet unless they have a channel to guide the tune. So if we take this as our starting position, there are two distinct curves, the primary curve, from the upper incisors, around the tongue and down to the laryngeal vestibule. This is set at an angle known as the vestibular axis. This then leads into the secondary curve, from the laryngeal inlet down the trachea. Raising the head with a pillow or head lift flattens the primary curve. How we negotiate the primary curve depends on the type of laryngoscope we use. A straight blade pretty much bypasses the curve, going around the tongue. A standard Mac or C-Mac blade flattens the primary curve, whereas an angulated device such as the King Vision, Glidescope or C-Mac D blade follow the curve. ET tubes dont readily follow the primary curve so we need an angulated bougie or stylet to deliver the tip of the tube to the glottis. Bimanual laryngoscopy, where we externally manipulate the larynx, can flatten the secondary curve, allowing us to gain a better view at laryngoscopy, but also to deliver a bougie or tube down into the trachea.When you understand that angulated devices deliver us to the glottis at a different angle, it is easy to see why tubes and bougies get stuck anteriorly, and why a right turn can help. 22

UNDERSTANDING THE LEARNER

Now we understand the physics and the stages of intubation we need to understand our learners. Why do they fail?23

GREYS ANATOMYThey dont understand the processThey dont know what they are looking for especially if slightly unusual looking larynx, oedema, blood, secretions, cords closed24

Time pressure. There is nothing like the sound of falling sats for inducing anxiety.25

Intubating your first few patients is more like cricket than baseball, because you dont get three strikes. Which is what makes cricket so stressful to play and watch. One false move and you are out. Stand aside.26

And be humiliated.27

TEACHING METHODS

1 2 3

Break laryngoscopy down into stages aka CHUNKINGSchemas to avoid sensory overload WHICH CAN CAUSE PARALYSISMaster one before the next e.g. 10 epiglottoscopies before moving onTeach them the physics29

www.airwaycam.com

Show them what they are looking for videos like Airway cam, or image libraries30

www.ccam.net.au

If you dont have an airway cam, you can get creative this is a video using a disposable bronchoscope taped to different laryngoscopesIt was meant as a teaching aid but got picked up by the Twittersphere as a new way of approaching tricky airways!31

@TBayEDguy

A whole rash of jerry rigged devices followed!32

This interesting study shows us another way of guiding our trainees towards the larynx. A simple LED torch applied over the front of the neck to light the way was associated with improved success rates. 33

There is little doubt that Videolaryngoscopes can help here too we can show the trainee what they are supposed to be seeing.We can also use them with the screen turned around, so that trainees can learn direct laryngoscopy while we have a reassuring view of whats going on.There are many studies showing that novices fare better with VL than with DL, but of more interest are the studies that show that training with a VL also improves subsequent performance with a standard Mac laryngoscope. 34

www.ctec.uwa.edu.au

How to get the numbers up without practising on patients?Cadavers might be gold standard, but access difficult, and they deteriorate over time

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www.airwaycam.com

Manikins and task trainers are improving, but will never be 100% lifelike. However, they do allow repetitive practice WITH NO HARM TO PATIENTSBottom right (Kyoto) has settings for neck stiffness, mouth opening, tongue size and laryngospasm36

There is a bewildering selection of airway devices out there. Only a small number of devices are required to deliver training based on the principles we have discussed. These should be the devices that are most commonly available. Otherwise a training program starts to resemble a trade fair. 37

SUPERVISED PRACTICE WITH IMMEDIATE FEEDBACK has been shown over and over to be effective, and it is popular with learners38

BALANCED WITH Auto didactism and guided discovery - 39

SIMULATION

For decision making:Failed intubation working through algorithmAirway management out of the comfort zoneAirway management in sick and unstable patientTrache emergenciesImproves Global Rating Scale assessment*

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Oh, just not smart. Even for you.

Repeated Workplace Based Assessments. Problems with these (choosing a supervisor, not handing in bad assessments)

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Once a trainee can be left to practice in isolation, video recording can help to eliminate this bias, make intervention procedure more normal and take some pressure off trainee44

Formative assessments during teaching sessionsGlobal rating scales binary data (successful vs failed intubation) not good enough for our patients who should not be practiced upon by novices or our trainees, who believe they have failed if they do everything right but dont get the tube in. ID of PERFORMANCE GAPSCUSUM Analysis but not just of binary data rating scale with scoresSuccess or failure not a good enough marker, and puts patients at risk. Simulation - evidence for improved performance intubation on GRS also useful for assessing NTS rating systems like ANTS45

Another way to ensure good preparation for intubation is the checklist this can be used as the basis of an assessment tool46

Improved educationAlgorithms and checklistsStandardised, simplified equipment and techniquesINTERDISCIPLINARY Sim and Human Factors Training47

Then hopefully our trainees can become Airway Ninjas, like Hit Girl here who has just performed a cricothyroidotomy using the scalpel-bougie technique. 48