ICU Director Duke University Medical Center, United States
Introduction: Prior studies have shown that there is significant variation between pulmonary and critical care (PCCM) training programs regarding education in airway management. To our knowledge, there has been no prior measure of how often fellows manage difficult airways. This study analyzed the exposure PCCM fellows had to difficult airways at a large tertiary teaching hospital.
Methods: A standardized template for intubation documentation in the electronic medical record (EMR) is used at our institution. Data from this template populates onto a dashboard associated with the EMR. We looked at all patients who underwent intubation in the MICU from September 2022 to July 2023. There were no exclusion criteria. The primary outcome was the incidence of difficult intubation. Descriptive statistics were performed on this data.
Results: 94 patients were intubated in the 10-month period. Fellows did 94.6% of intubations with 36% being post-graduate year (PGY) 4, 52.8% PGY5, and 11.2% PGY6. Nine patients (9.6%) were documented as having a difficult airway. Views during video laryngoscopy (VL) were noted with 60.6% grade 1, 28.7% grade 2a, 6.4% grade 2b, 2.1% grade 3, and 2.1% without a grade documented. Patients were intubated for multiple reasons, primarily 23.4% for respiratory causes, 30.8% for airway protection, and 17.0% for procedures. In addition, 23.4% of patients were hemodynamically unstable during intubation and 74.5% of patients were on high levels of respiratory support prior to intubation. Despite this, the first pass success rate of intubation was 92.6%. 100% of the intubations were done by VL.
Conclusions: Most intubations in the MICU were performed by fellows, but they had little exposure to difficult airways. They did have notable exposure intubating patients experiencing active respiratory failure or hemodynamic instability. The first pass success rate was high. Limitations include the reliance on EMR documentation for data. Some intubations may have been documented using a non-standard template. Our findings suggest that training programs should not only look at numbers of intubations but should ensure fellows’ exposure to difficult airways and ensure training with a variety of techniques of intubation.
