Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.

1. Anyone Can Intubate
or Not
Teaching & Learning Airway
Management the Antifragile Way
George Kovacs MD MHPE FRCPC
Professor, Departments of Emergency Medicine, Anaesthesia
Medical Neuroscience & Division of Medical Education
Dalhousie University, Halifax Nova Scotia
gkovacs@dal.ca
@kovacsgj
AIMEairway.ca

2. 2
@kovacsgj
AIMEairway.ca

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8. 355

14. Anyone Can Intubate!!

16. 16
Successful Airway
Management

18. First Pass
Success

23. Success…
• 90 % FPS
• >90 % sat
• >90 mm Hg
• <90 sec

24. Becoming Successful
Competence
Context
Confidence
Conscientiousness

25. Competence
Context
Confidence
Conscientiousness
Avoiding Failure ?

26. Competence
Program
Practice
Feedback

27. Competence/Performance
Do
Show how
Know how
Know
Miller GE. The assessment of clinical skills/competence/performance. Acad Med.1990

28. Does
Competence
Performance

29. How Much Practice

30. “The greats weren’t great cause at birth they
could paint. The greats were great cause they
painted a lot.”

31. Practice- How often?

32. Math 101
• Owning the airway?

33. Math 101
• 75,000 Patient visits
• 500 ETI’s/year
• 9 shifts/day
• 15 shifts/month
• 2-3 resusc area/month
• How many tubes?

34. during laryngoscopy is supported by the findings of
Nouruzi-Sedeh et al., who found that the main diffi-
culty for novices was in obtaining a good laryngeal
view within 120 s [12]. In addition, Aziz et al. found a
65% incidence of failure involving inadequate laryngeal
views in a observational study of 2004 GlideScope
intubations [23].
The findings of this study are limited in that it
includes a small number of individuals in a single
institution, with the possibility that the findings may
not generalise to other institutions. However, the large
number of intubations studied, the statistical homoge-
neity of subjects/case difficulty and the gradual pro-
0
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1
0 20 40 60 80 100
Probabilityofoptimalintubation
Experience
Figure 1 The probability of optimal intubation pre-
dicted by mixed-effects logistic regression model.
Cortellazzi et al. | GlideScopeâ
tracheal intubation expertise Anaesthesia 2014
75? >100?
Resuscitation xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
Review article
Defining the learning curve for endotracheal intubation using direct
laryngoscopy: A systematic reviewଝ,ଝଝ
Maria L. Buis∗Q1 , Iscander M. Maissan, Sanne E. Hoeks, Markus Klimek, Robert J. Stolker
Department of Anaesthesiology, Erasmus University Medical Centre, Office H-1286, ’s-Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsQ2
a r t i c l e i n f o
Article history:
Received 31 July 2015
Received in revised form 4 November 2015
Accepted 11 November 2015
Keywords:
Learning curve
Direct laryngoscopy
Intubation
a b s t r a c t
More than two failed intubation attempts and failed endotracheal intubations (ETIs) are associated with
severe complications and death. The aim of this review was to determine the number of ETIs a health care
provider in training needs to perform to achieve proficiency within two attempts. A systematic search of
the literature was conducted covering the time frame of January 1990 through July 2014. We identified
13 studies with a total of 1462 students who had attempted to intubate 19,108 patients. This review
shows that in mostly elective circumstances, at least 50 ETIs with no more than two intubation attempts
need to be performed to reach a success rate of at least 90%. However, the evidence is heterogeneous,
and the incidence of difficult airways in non-elective settings is up to 20 times higher compared to
elective settings. Taking this factor into account, training should include a variety of exposures and should
probably exceed 50 ETIs to successfully serve the most vulnerable patients.
© 2015 Published by Elsevier Ireland Ltd.
Introduction
Q3
Failed intubation is the most frequently reported complica-
tion in airway management according to a recent British survey.1,2
Numerous (>2) attempts and failed endotracheal intubations (ETIs)
are associated with oxygen desaturation, arrhythmias, cardiac
arrest, brain damage, and mortality.3–6 The most critical patients
deserve the best-skilled health care providers, and the more
experienced the physician, the higher the chance of a successful
intubation.7 As for all manual skills, ETI is subject to a learning
curve.8
ETI skills should be developed in a structured training pro-
gramme, which is especially relevant for those who intubate in
non-elective or emergency settings where the incidence of a dif-
ficult or failed intubation is up to 20 times higher than in the
elective setting.3 In the Netherlands, training programmes for non-
anaesthesiologists who perform ETIs currently do not require a
minimum number of completed ETIs.9
The aim of the present study was to provide a systematic review
of the literature on the learning curve for ETIs. Because direct
ଝ A Spanish translated version of the abstract of this article appears as Appendix
in the final online version at http://dx.doi.org/10.1016/j.resuscitation.2015.11.005.
ଝଝ This review was presented at the Dutch Anaesthesiology Congress, May 29,
2015, Maastricht, The Netherlands.
∗ Corresponding author.
E-mail address: m.buis@erasmusmc.nl (M.L. Buis).
laryngoscopy (DL) is the most widely used technique pre-hospital
and in-hospital, we reviewed the learning curves for this proce-
dure. We specifically aimed to identify the number of ETIs a novice
intubator must perform to achieve proficiency with this procedure,
defined as successfully intubating within two attempts.
Methods
Study selection
This review was performed according to the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses (PRISMA) state-
ment. A search of the literature (January 1990–July 2014) was
performed using EMBASE, MEDLINE, Web of Science, Cochrane
Central Register of Controlled Trials (CENTRAL), and PubMed. The
following keywords were used for the search: ‘intubation’, ‘learn-
ing curve’, and ‘laryngoscopy’. The search was limited by excluding
the keywords ‘videolaryngoscopy’ and ‘paediatrics’. The full elec-
tronic searches can be found in Appendix A. In addition, we hand
searched the reference sections of all articles that were selected for
review.
Inclusion criteria were English-language only, human studies
only, DL as the sole procedure, novice participants or number of
previously performed intubations clearly identifiable, and speci-
fied quantification of the success rate learning curve for ETI. Studies
were excluded if they had been conducted in a simulation labora-
tory, were limited to paediatric patients only, involved ETI using a
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40-80?
Bernhard et al. 2012
Acta Anaesthesiologica Scandinavica
Cortellazzi et al. 2015 Anaesthesia

35. The pursuit & consequence
of the search for easy…

36. 1stAttemptSuccessRates
0
25
50
75
100
Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2014 Hypes 2016 Total
VL
DL 68%
80%
Total ~2500 in each DL & VL
In pursuit of easy…
VL is better…

37. 1stAttemptSuccessRates
0
25
50
75
100
Sackles 2011 Mosier 2013 Kory 2013 Michalideu 2014 Lee 2014 Silverberg 2014 Sakles 2014 Hypes 2016 Total
VL
DL 68%
80%
17,000 Registry PatientsDL 84%
In pursuit of easy…
VL is better than bad DL

38. Tell me what you see?

39. Do you see the posterior
cartridges?

40. Competence
Context
Confidence
Conscientiousness
Context: materials

41. 5 Faces
Context

42. 7,000,000,000

43. 43

44. High Acuity Low Opportunity
Challenge
Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013
High Acuity
Low Opportunity
Low Acuity
Low Opportunity
High Acuity
High Opportunity
Low Acuity
High Opportunity
Opportunity
Acuity
Sim
Zone
Overlearn

45. Opportunities… Overlearn

46. Opportunities… Overlearn

47. Context: environment
High
Stakes

48. These are your vitals

49. Times of stress
Challenge Threat

50. Grossman & Christensen. On Combat 2008

51. Don’t avoid failure
…be antifragile

52. High Acuity Low Opportunity
Challenge
Petrosoniak & Hicks. Current opinion in Anaesthesiology. 2013
High Acuity
Low Opportunity
Low Acuity
Low Opportunity
High Acuity
High Opportunity
Low Acuity
High Opportunity
Opportunity
Acuity
Sim
Zone
Overlearn
System 1 training

53. System 1 training
Learn as Many/Execute as 1
Incrementalization
8
- The “secret “ of competence in crisis is to break down the
challenge into smaller parts, and then incrementalize it into its
smallest, most fundamental components.
- Operators should master a regimented series of best-practice
steps that are small, reliable, and reproducible. Expertise is the
ability to do each task well, transforming incrementalized steps
into one fluid, apparently easy, and effortless movement.
- Slow is smooth and smooth is fast. Rushing deteriorates
performance. Multi-tasking is a myth.
- Procedures should be engineered for crisis performance, by
flattening the slope, and lightening the load.
- Slope: Incrementalization
- Load: Cognition

54. System 1 training:
Avoid Insanity
I can’t see %$^&!!!

55. System 1 training:
Cued Response
• Epiglottoscopy
• Valleculoscopy
• Laryngoscopy
• Intubation
AIMEairway.ca: SMACC Byte- Airway Management Kata
Epiglottis only response

56. Cued Response:
Psychomotor rehearsal
EVLI
Learn as Many/Execute as 1

57. Best Look DL&I
Cued Response:
Psychomotor rehearsal
Learn as Many/Execute as 1

58. Competence
Context
Confidence
Conscientiousness
Confidence

59. “we all got plans, til you get
punched in the mouth”
Confidence

60. Number Needed to be…
Confident

61. Confidence
Experience
Confidence

62. Good judgment is the
result of experience and
experience the result of
bad judgment

63. Conscientiousness
Competence
Confidence
Context

64. 64
… work ethically
Conscientiousness

65. It’s not about you

66. Its about the patient

67. 67
Conscientiousness
… work ethic

68. 68
Conscientiousness
… work ethic

69. 69
Conscientiousness
Doing
Knowing
… work ethic

70. Plan A
Plan CPlan B
Airway Tool Box
Do
Know

71. Plan A
Plan CPlan B
Airway Tool Box
Do
Know

72. Fear of Failure
Competence
Context
Confidence
Conscientiousness

75. Anybody can intubate

76. Anybody can intubate
Competence
Context
Confidence
Conscientiousness

79. Anyone can intubate

80. Thank You