Do You See Anything That You Recognize: Teaching Novice Student Registered Nurse Anesthetists to

Intubate Using the GlideScope

Stephanie K. McHenry, CRNA, MSN, ARNP

Introduction

• CRNAs in US provide over 33 million anesthetics safely to patients’ annually (American Association of Nurse Anesthetists ,2011)

• Endotracheal intubation – Most crucial skill for CRNA– Difficult to Master (Howard-Quijano, K. J., Huang, Y. M., Matevosian, R., Kaplan,

M. B., & Steadman, R. H, 2008)

• 50 intubations to achieve 90% success rate on Mallampati I and II (Konrad, C., Schupfer, G., Wietlisbach, M., & Gerber, H. ,1998) – Variables associated with anatomic landmarks of real patients– Anatomic drawings and manikin modules do not adequately represent anatomy

• Novice success rate 45% for first 10 intubations (Ayoub, C. M., Kanazi, G. E.,

Al Alami, A., Rameh, C., & El-Khatib, M. F., 2010). – affects confidence levels – Influences performance in other areas of clinical experience (Chipas, A., Cordrey,

D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B., 2012, August)

Introduction • Endotracheal intubation difficult skill to teach (Howard-Quijano, K. J,

2008)– Restricted time– Limited visual perspective

• Video Laryngoscope (VL) as a teaching aide (Kaplan, M. B., Ward, D., Hagberg, C. A., Berci, G., & Magiike, M., 2006) – Reduces instructor and student frustration– Allows simultaneous visualization of airway– Shortens student’s intubation learning phase (Herbstreit, F., Fassbender,

P., Haberl, H., Kehren, C., & Peters, J. 2011) – Skills developed to use during difficult intubations (Herbstreit, F., 2011)

• Previous research examined use of VL to teach EMTs and doctoral students with success

• No research published implementing the VL as a instructional aid for SRNAs.

Literature Research

Included

Peer reviewed journals included in the study ( n=9)

Eligibility

Full Text articles assessed for eligibility (n=21) Excluded mixed method teaching methods and other aspects besides intubation

Screening

Records screened (n=150)Included research articles where the Video Laryngoscope was used to teach intubation

Excluded case studies, reviews and letters to the editor

Excluded

Records Excluded (n= 593) Non-peer review journals, not available in English or duplicate studies

Records indentified through database searching (n=78)

Additional records identified through other sources (Cohrane Database, dissertation abstracts, IBIS, Reference in other articles (n =536)

Results• Video-assisted techniques used to teach many

surgical disciplines• Several types of Laryngoscopes are used by

Anesthesia (Kaplan, 2006)

• Benefits of Laryngoscopes to teach intubation– Used for difficult intubations– Improved intubation success rate (Kaplan, 2006) (Herbstreit,

2011)

– Less time to intubation (Ayoub, 2010)

– Increased knowledge of anatomy (Low, 2008)

– Decreased number of attempts to obtain a level of competency (Howard-Quijano, 2008) (Nouruzi-Sedeh 2009)

Integrative Review : Using the Video Laryngoscope to Aide Tracheal Intubation Instruction

Type of Video Laryngoscope Used in Research Studies

Teaching ModuleIntubation Video

3, 11,13

*Show 15 actual laryngoscopes via view from intubator

*Shows all anatomical structures in sequence

*Allow online access to video

Lecture

3,11,12, 13

*Airway Anatomy

*Proper Intubation/Positioning techniques

*Airway Management

*How to use the GlideScope

*Familiarization with Equipment

Simulation /Mannequin

3, 8,11, 12, 13 ,18

* "Easy" simulator first

* Feedback on technique

* Repeat until able to demonstrate consistent

satisfactory performance

* Introduce difficult intubation scenarios as well

as expose to alternative difficult intubation aids

Clinical Practice- Macintosh Blade

11,12

* 5 intubations

* Allows for proper equipment setup

* Experience intubating actual patient

* If student cannot visualize cords about

attempt and ventilate

Clinical Practice - Video Laryngoscope

2, 3, 11,12

*10 intubations

* Best opportunity to visualize anatomical

structures

Return to Macintosh Blade

* Video Laryngoscope used for anticipated

or encountered difficult airways

Competence and Confidence

3,8, 11

* Air management skills

*Use of Video Laryngoscope

Summary

• Monocularity causes students to struggle to learn the skill of intubation using the traditional laryngoscope

• Slight anatomical differences may impede successful laryngoscopy.

• Implementing the Video Laryngoscope as a teaching tool– Provides instantaneous feedback– Leads to increased proficiency– Improves learning– Increases competence– Improves patient safety

References

• American Association of Nurse Anesthetists. (2011). Certified Registered Nurse Anesthetists at a glance. Retrieved from http://www.aana.com/ceandeducation/becomeacrna/Pages/Nurse-Anesthetists-at-a-Glance.aspx

• Howard-Quijano, K. J., Huang, Y. M., Matevosian, R., Kaplan, M. B., & Steadman, R. H. (2008). Video-assisted instruction improves the success rate for tracheal intubation by novices. British Journal of Anesthesia, 101(4), 568-572.

• Ayoub, C. M., Kanazi, G. E., Al Alami, A., Rameh, C., & El-Khatib, M. F. (2010). Anesthesia. Tracheal intubation following training with the GlideScope compared to direct laryngoscopy, 65, 674-678.

• Konrad, C., Schupfer, G., Wietlisbach, M., & Gerber, H. (1998). Learning manual skills in Anesthesiology: Is there a recommended number of cases for anesthetic procedures. Anesthesia Analogue, 86, 635-639.

• Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012, August). Stress: Perceptions, manifestations, and coping mechanisms of Student Registered Nurse Anesthetists. AANA Journal, 80(4), S49-S56.

• Weiss, M., Schwarz, U., Dillier, C. M., & Gerber, A. (2001). Teaching and supervising tracheal intubation in pediatric patients using video laryngoscopy. Pediatric Anesthesia, 11, 343-348.

• Kaplan, M. B., Ward, D., Hagberg, C. A., Berci, G., & Magiike, M. (2006). Seeing is believing: the importance of video laryngoscopy in teaching and in managing the difficult airway. Surgical Endoscopy, 20, S479-S483.

• Herbstreit, F., Fassbender, P., Haberl, H., Kehren, C., & Peters, J. (2011, April 22). Learning endotracheal intubation using a novel video laryngoscope improves intubation skills of medical students. Anesthesia-analgesia, 1-5.

• Whittemore, R., & Knafl, K. (2005). The integrative review: updated methodology. Journal of Advanced Nursing, 52(5), 546-553.

• Cooper, H., & Koenka, A. (2012). The overview of review: Unique challenges and opportunities when research syntheses are the principle elements of new integrative scholarship. American Psychologist, 67(6), 446-462.

• Low, D., Healy, D., & Rasburn, N. (2008). The use of the Berci DCI Video Laryngoscope for teaching novices direct laryngoscopy and tracheal intubation. Anesthesia, 26, 195-201. 

References

• Nouruzi-Sedeh, P., Schumann, M., & Groeben, H. (2009). Laryngoscopy via Macintosh Blade versus GlideScope. Anesthesiology, 110, 32-37.

• Levitan, R. M., Goldman, T. S., Bryan, D. A., Shofer, F., & Herlich, A. (2001). Training with video imaging improves the initial intubation success rates of paramedic trainees in an operating room setting. Annals of Emergency Medicine, 37(1), 46-50.

• Shorten, G. D., & Roberts, J. T. (1991). Some applications of fiberoptics in anesthesia. Anesthesiology Clinics of North America, 9, 187-193.

• Higgins, M. S., Deshphande, J. K., & Badr, A. (1996). A new video system improves teaching of direct laryngoscopy. Anesthesiology, 84, 1010-1011.

• Tarasi, P., Mangione, M. P., Singhal, S. S., & Wang, H. E. (2011, August). Endotracheal intubation skill acquisition by medical students. Medical Education Online, 16. http://dx.doi.org/10.3402/meo.v16i0.7309

• Ericcson, K. A., Krampe, R. T., & Tesch-Romer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363-406.

• Owen, H., & Plummer, J. L. (2002). Improving learning of a clinical skill: the first years’ experience of teaching endotracheal intubation in a clinical simulation facility. Medical Education, 36, 635-642.

• Plummer, J. L., & Owen, H. (2001). Learning endotracheal intubation in a clinical skills learning center: a quantitative study. Anesthesia Analogue, 93(3), 656-662.

• El-Orbany, M. (2012). Will direct laryngoscopy become an extinct skill? Act Aneaestheiologica, 56, article 260.• Anderson, L. H., Rovsing, L., & Olsen, K. S. (2011). GlideScope videolaryngoscope vs. Macintosh direct laryngoscope

for intubation of morbidly obese patients: a randomized trial. Acta Anesthesiologica Scandinavica, 55, 1090-1097.• Abdallah, R., Galway, U., Kurz, A., Sessler, D. I., & Doyle, D. J. (2011). A randomized comparison between the Pentax

AWS video laryngoscope and the Macintosh laryngoscope in morbidly obese patients. Anesthesia & Analgesia, 113, 1082-1087.

• Aziz, M., Dillman, D., Kirsch, J., & Brambrink, A. (2009). Video laryngoscopy with the Macintosh Video Laryngoscope in simulated prehospital scenarios by paramedic students. Prehospital emergency care, 13, 251-255.