Knowledge and skills in setting up videolaryngoscopes
Emily Pallister, Achuthan Sajayan and Cyprian Mendonca conducted a survey among operating departmental practitioners at a teaching hospital, looking at ODP training in airway management and the general knowledge of videolaryngoscopes
Videolaryngoscopes have been proven to be useful in managing difficult intubation [1–4]. They transmit the image to an external monitor, from a miniature video camera placed at the distal end, via a fibreoptic bundle or a system of prisms. Some of them have an inbuilt tube channel that directs the tracheal tube into the larynx. Others require a stylet to direct the tracheal tube into the larynx. At University Hospital Coventry and Warwickshire (UHCW) there are six different videolaryngoscopes available. These comprise three channelled videolaryngoscopes (Airtraq, King Vision and Pentax AWS) and three non-channelled videolaryngoscopes (C-MAC, McGrath and Glidescope). From an anaesthetist’s perspective these videolaryngoscopes are widely available to use in theatres, and commonly feature in the airway management plan for an anticipated difficult airway. Training sessions are regularly held in the Coventry Airway Lab for intubation practice on mannequins.
Although the set up and assembly of these devices can be self-explanatory, knowledge of their maintenance and cleaning are also essential for the operator and the operating department practitioner (ODP). These skills are taught in the airway lab sessions; however, infrequent or variable use of the devices in daily practice means that this knowledge can often be lost. A survey was designed to gauge the knowledge, training and confidence of ODPs in the use and maintenance of videolaryngoscopes. Their assistance in the management of a difficult airway can be invaluable, and as such there is a requirement to have up-to-date skills in the use and maintenance of any device that the anaesthetist may ask for. ODPs are invited to attend videolaryngoscope sessions and refreshers in the airway lab to keep their skills current. The survey tested whether the level of confidence with videolaryngoscopes among ODPs was substantiated by relevant training, and, therefore, whether training was proving accessible and appropriate.
A survey questionnaire was designed to ascertain knowledge on location and availability of videolaryngoscopes, experience and confidence in setting up of videolaryngoscopes among ODPs. They were also asked whether they have received any formal training in setting up and maintenance of videolaryngoscopes.
ODPs from main operating theatres were surveyed over a two-week period. The cohort questioned included ODPs from all main specialities including cardiac, general, vascular, trauma and orthopaedic, gynaecology and neurosurgery. ODPs were asked how long they had been working as an ODP to see if there was correlation between the results and years of experience, and whether they had attended airway courses in the past two years.
From a list of seven possible videolaryngoscopes, ODPs were asked to identify the six available at UHCW. They were asked which of these they had used, and which they had received formal training for. ‘Formal training’ was described as having attended a lecture on the use of this videolaryngoscope, or having received training in a session in the airway lab or similar. Participants were then asked if they knew which, if any, of the videolaryngoscopes were available on the difficult airway trolley, and how they would find any given videolaryngoscope. At the end of the survey participants were invited to give any feedback they wished on the training they had received to date. The results were analysed using a Microsoft Excel spreadsheet.
Results and discussion
In total, 28 ODPs participated in this survey. There are estimated to be around 40 ODPs working within the department. Most commonly the respondents had been working either less than five, or over ten years as an ODP. Eleven (39 per cent) respondents stated that they had been to a training session on videolaryngoscopes in the airway lab. Another eight ODPs had been on the Coventry airway management course, and eight on the SMART anaesthesia course, although it is noted that some ODPs had been on more than one course (Figure 1).
All six videolaryngoscopes were correctly identified by 96 per cent of respondents. All of the ODPs surveyed were able to recognise that the Airtraq and Pentax AWS were available, with 27 respondents correctly identifying the other four. The majority of them (79 per cent) had assisted the anaesthetist in using all six of the videolaryngoscopes. The videolaryngoscope that the respondents had most experience with was the Pentax AWS (26 respondents; 93 per cent). The level of confidence in setting up videolaryngoscopes was high and closely reflected the experience demonstrated, and 75 per cent (21) of respondents felt confident in the use of all videolaryngoscopes, with only two respondents (7 per cent) stating ‘not sure’ to this question. It was noted that the ODPs who had attended airway courses in the past two years were more likely to indicate confidence with the videolaryngoscopes. This demonstrates the effectiveness of local airway training in improving confidence with these devices (Figure 2).
The ODPs were asked to indicate which of the available videolaryngoscopes they felt confident with. The scores were bracketed in to confidence with 50 per cent, 90 per cent or all of the devices. For the purposes of the chart shown in Figure 2, ‘YES Confident’ indicates that the ODP felt confident in the use of over 90 per cent (ie five out of six) of the videolaryngoscopes on offer. This was then cross-referenced against whether they had attended an airway course in the past two years.
Interestingly, the training for the use of these videolaryngoscopes varied greatly and did not correlate with the level of confidence stated. Among the different videolaryngoscopes, between four and 11 respondents stated that they had received formal training. Again, most commonly, ODPs had received training on the use of Pentax AWS (11 respondents, 39 per cent), with only four ODPs having been trained for McGrath (14 per cent). None had received training on all of the laryngoscopes, and 15 ODPs stated that they had not received formal training to use any of the videolaryngoscopes (54 per cent) (see Figure 3). Hence for many ODPs, confidence with videolaryngoscopes is gained through experience rather than training. It is thought that this may reflect the confidence level in ODPs who had not attended airway courses (who were more likely to be confident with almost all of the devices) as some ODPs would only state confidence in those devices that they had used before. With greater attendance on airway courses it is likely that more ODPs would gain confidence with more of the videolaryngoscopes.
Only 11 ODPs (39 per cent) knew that there are no videolaryngoscopes on the difficult intubation trolley. Other answers to this question showed great variety and generally a poor knowledge of the content of a difficult airway trolley (Figure 4). AirTraq was most often thought to be on the trolley (11 respondents), and only three admitted that they were unsure.
Results indicated that the majority of ODPs (23 respondents, 85 per cent) were aware of the posters in theatre outlining where the different videolaryngoscopes are stored. These are generally the easiest method to locate a videolaryngoscope, and are widely distributed with each of the anaesthetic rooms having a copy. Other methods listed included prior knowledge (three respondents; 11 per cent), a list on their email (two respondents; 7 per cent) and asking colleagues or word of mouth (one respondent; 4 per cent). All of the methods listed are valid.
When asked if they thought ODPs should receive regular training on videolaryngoscopes, 27 out of 28 respondents (96 per cent) answered ‘yes’. ODPs gave the following comments regarding training:
- Training would be useful, especially for newly qualified staff.
- I would like to participate on any available courses in the near future.
- All ODPs should have difficult airway training at least once a year and updates on videolaryngoscopes at least for newly qualified ODPs.
- I think all newly qualified ODPs should attend Airway Lab sessions or Airway Management course within the first year of working.
- Regular training on all types of airway equipment would be beneficial to all ODPs.
Airway training for ODPs
Following the original survey, a drop-in session for ODPs was held in the airway lab. All ODPs were invited to attend through direct word of mouth and hospital email. The session was held during a theatre QIPS half-day session when lists were suspended and most ODPs were free to attend the session. They were invited to re-familiarise themselves with the different videolaryngoscopes. Running the session as a drop-in meant that it was informal, and importantly provided an impartial environment for the ODPs to ask any questions. The session featured all six videolaryngscopes with opportunity to intubate mannequins.
Feedback was collected for the session itself, and regarding the use of videolaryngoscopes within the Trust. The feedback was very encouraging and is summarised in Table 1. There was a slight improvement in how confident the ODPs felt in the use of videolaryngoscopes prior to and following the session – with the average score increasing from 3 to 3.8; however, the range of scores for these questions showed a positive trend towards general increased confidence. The lower range of the score increased from 1 to 3, showing that more ODPs felt more confident with videolaryngoscopes after the session. The session was well received by those who attended, and all those who gave feedback agreed or strongly agreed that they would like similar sessions in the future.
Responses to the survey demonstrated that generally ODPs at UHCW were confident with the use of the videolaryngoscopes on offer. The ODPs that had attended an airway course recently were more likely to be confident with almost all of the devices, with others showing confidence only in the devices that they had used before.
Hence it is concluded that regular formal airway training in the airway lab or on airway management courses is more likely to improve confidence in the use of all the videolaryngoscopes on offer. Regular training is recommended to ensure that ODPs are rightly confident in the use of videolaryngoscopes, and to gauge whether their knowledge of maintenance and cleaning of these devices is correct.
Imperative to this training is revision of the difficult airway trolley, as fewer than 40 per cent of respondents knew that the trolley does not contain videolaryngoscopes. Improvements must also be made in making accessories more accessible and easier to find, and to ensure that a list outlining the location of each of the videolaryngoscopes is available in all theatres.
- Niforopoulou P, Pantazopoulos I, Demestiha T, Koudouna E, Xanthos T. Video-laryngoscopes in the adult airway management: A topical review of the literature. Acta Anaesthesiol. Scand. 2010; 54:1050–61
- Griesdale DEG, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anesth 2012;59:41–52
- Thong SY, Lim Y. Video and optic laryngoscopy assisted tracheal intubation – The new era. Anaesth Intensive Care 2009;37:219–33
- Zaouter C, Calderon J, Hemmerling TM. Videolaryngoscopy as a new standard of care. Br J Anaesth 2015; 114: 181–3
Emily Pallister is a specialist trainee at Warwickshire School of Anaesthesia.
Achuthan Sajayan is a consultant anaesthetist at the Heart of England Foundation Trust in Birmingham.
Cyprian Mendonca is a consultant anaesthetist at the University Hospitals Coventry & Warwickshire NHS Trust in Coventry.
Correspondence to Emily Pallister