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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 90-97

Simulator-based videolaryngoscopy training for capacity building in intubation during COVID-19 pandemic: An institutional experience from North India

1 Department of Anaestheiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Emergency Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Physiology and CPD, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
4 Department of Pathology and CPD, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission29-Apr-2021
Date of Acceptance12-Jun-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Sanjay Agrawal
Department of Anaesthesiology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_25_21

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Background: Coronavirus disease 2019 (COVID-19) pandemic has presented the healthcare sector with unique challenges. The use of a videolaryngoscope (VL) for intubation is one of the recommendations. The paucity of availability of VL outside the operation room results in lack of intubation skills with VL among clinicians. This study was undertaken to analyse the effectiveness of fast-tracked simulation-based training in enabling frontline resident doctors with skills of videolaryngoscopy. Material and Methods: Residents already trained in the skills of direct laryngoscopy underwent training on VL using the King Vision™ VL (channeled blade) through structured simulation-based training in batches of <20. Sessions included interactive lecture, demonstration by the instructor and supervised hands-on practice by residents on an airway manikin. Knowledge gained was assessed with multiple-choice questions through a pre-test and post-test. Skills gained were assessed through Objective Structured Clinical Examination (OSCE) and Direct Observation of Procedural Skills (DOPS). Feedback was taken from participants on a 3-point Likert scale. Results: 190 residents were enabled with skills of videolaryngoscopy within 3 months. Overall mean pre-test scores of 6.16 ± 1.79 improved to 7.21 ± 2.02 in post-test scores and improvement in knowledge was found to be statistically significant (P < 0.0001). Skill assessment through DOPS revealed excellent performance by 72% of participants while 3% scored borderline. OSCE results showed overall good performance by residents across various clinical disciplines. 90.4% of participants responded that training gave them the confidence to perform videolaryngoscopy. Conclusion: A well-structured simulation-based training on videolaryngoscopy is effective in imparting indirect airway management skills to residents of various clinical specialties. Simulation-based fast-tracked training is an effective method to train a large number of clinicians within a limited period.

Keywords: Airway, coronavirus disease 2019, endotracheal intubation, King Vision™ videolaryngoscope, simulation-based training

How to cite this article:
Agrawal S, Pathak S, Bhardwaj BB, Arora P, Kabi A, Kathrotia R, Rao S. Simulator-based videolaryngoscopy training for capacity building in intubation during COVID-19 pandemic: An institutional experience from North India. Airway 2021;4:90-7

How to cite this URL:
Agrawal S, Pathak S, Bhardwaj BB, Arora P, Kabi A, Kathrotia R, Rao S. Simulator-based videolaryngoscopy training for capacity building in intubation during COVID-19 pandemic: An institutional experience from North India. Airway [serial online] 2021 [cited 2022 Jan 27];4:90-7. Available from: https://www.arwy.org/text.asp?2021/4/2/90/323571

  Introduction Top

Simulation-based training is an important tool for the acquisition of new skills as well as improving previously acquired skills. Simulation is being increasingly used to create difficultly and challenging clinical scenarios, thus helping the trainees to learn and practice before performing these skills on real patients. Coronavirus disease-2019 (COVID-19) pandemic presented a challenging situation to the healthcare sector due to its highly infectious nature. Its novel nature of spread presented a situation where the healthcare worker himself or herself was at high risk for infection due to proximity to tracheobronchial and oropharyngeal secretions which have a high viral load. In the beginning of the pandemic, the medical sector was not adequately prepared to face the challenges due to the paucity of information. Most of the patients affected with COVID-19 infection develop mild illness and recover without requiring hospital admission while 15% manifest severe symptoms and 5% develop critical illness requiring mechanical ventilation.[1] Ventilator management for these patients includes high flow nasal oxygenation, noninvasive or invasive ventilation (with endotracheal intubation). Videolaryngoscopy (VLS) is recommended in COVID-19 patients requiring intubation.[2],[3],[4] This is because intubation is an aerosol-generating procedure which may liberate highly infectious virus into the air and spread it to the physician performing the procedure.[5] Evidence in literature documents that the videolaryngoscope (VL) is a rescue device in situations posing difficult intubation as well as in failed direct laryngoscopy.[6] As changing equipment following failed intubation may delay airway resuscitation, a better option would be to use a VL routinely for optimally managing the critical situation when oxygenation is most essential. This is because oxygenation takes priority over any intervention and it is the primary reason for intubation.[7] Videolaryngoscopes are most effective for achieving this goal in COVID-19 patients. As VLs are already in the armamentarium of the anaesthesiologist, they are usually available in the operating room (OR). However, training on VL is suboptimal for those working outside the OR such as in Emergency Medicine and the Intensive Care Unit (ICU).[8],[9] The current COVID-19 pandemic posed a peculiar problem with risk to healthcare workers (HCWs) while delivering patient care and hence necessitated the health sector to strengthen the healthcare set-up and make it better equipped to ensure optimal patient care while at the same time safeguarding the health of HCWs.

At the start of the COVID-19 pandemic, it was decided that all residents involved in patient care at our Institution, who could be performing intubation at some time, be trained in videolaryngoscopy. Teaching during the pandemic also posed significant challenges and hence the residents were trained in small batches, strictly following the norms of social distancing. The aim of the training was to make these residents proficient in the use of a VL for intubation of suspected COVID-positive patients in the Emergency Department. The study was undertaken to analyse the effectiveness of a fast-tracked, skill-based training programme delivered to enable these frontline resident doctors with skills of videolaryngoscopy. The utility of Direct Observation of Procedural Skills (DOPS) as an assessment tool to evaluate trainee competence at the end of training in a skill laboratory setting was also assessed.

  Material and Methods Top

The study analysed data obtained during the training sessions of residents from various specialities who were trained between June and August 2020 in batches of 20 residents. These were mandatory training sessions for residents of the Institute. They were conducted as a learning activity at the Advanced Centre of Continuous Professional Development (CPD) at the All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttaranchal. Ethical exemption was obtained from the Institutional Ethics Committee (IEC) (AIIMS/IEC/20/858 dated 28 December 2020) for analysis and presentation of the data. The training was conducted in batches of 20 residents each ensuring that all necessary precautions were taken to prevent transmission of COVID-19 infection between participants. All these residents were well versed in skills of basic airway management and intubation with conventional laryngoscope before their training with VLs.

Participants were assessed with pre-test for baseline knowledge on videolaryngoscopy through multiple-choice questions (Google forms) before starting the training. The training session was divided into three submodules and uniformity was maintained for the delivery of content to all the participants during multiple training sessions. The first submodule was theoretical training regarding VL using the King Vision™ VL through an interactive well-structured short lecture using a slide presentation on requirements, technique and case-based situations for videolaryngoscopy. This was followed by skill-based practical training given by the airway expert on a low fidelity airway manikin wherein the King Vision™ VL and its parts were explained and the procedure of VL was demonstrated. The next submodule focused on demonstrating the exact technique of intubation using the King Vision™ VL. The last and final session included the actual performance of videolaryngoscopy by residents on the airway manikin. The same expert who trained the residents also assessed skills gained through Objective Structured Clinical Examination (OSCE) and DOPS during their hands-on training session using a structured checklist which was prevalidated by airway experts of the Institute. A team of two experienced Anaesthesiologists trained the residents in VL and helped them acquire this new skill.

All residents were given similar clinical scenarios to perform during their hands-on sessions. The simulation scenarios covered situations pertaining to emergency intubation in COVID patients. During these simulation scenarios, the resident was assessed based on DOPS as described in [Table 1]. Each resident was allotted a single scenario and was expected to achieve intubation of the airway manikin using a King Vision™ VL. A debriefing session was carried out after each scenario so that the trainees could improve their knowledge and learn from their mistakes. During the debriefing sessions, details about the steps missed/not performed correctly as per the DOPS scale [Table 1] were explained. The participants were encouraged to ask questions and clear their doubts throughout the training.
Table 1: Direct observation of procedural skills - based practical assessment by using checklist comprising of 12 criteria

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At the end of all the training sessions, the trainees were assessed on knowledge by a post-test consisting of the same set of questions as was used in the pre-test. DOPS assessment was used to evaluate the acquisition of skills in the post-test. DOPS assessment for videolaryngoscopy was based on a 12-point criteria [Table 1] which was overall scored as Excellent (11–12), Good (9–10), Fair (7–8) and Poor (<6). Assessment by OSCE was done on specific parameters such as donning of personal protective equipment (PPE), selection of the appropriate device, checking of the endotracheal tube (ETT) and other parameters as listed in [Table 2].
Table 2: Technical laryngoscopy and intubation-related skill assessment of anaesthesia (n=73) versus non-anaesthesia (n=113) trainees

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Feedback was taken from participants about their experience and perception for the training modules, as also knowledge and skill acquisition on a 3-point Likert scale. Pre-test and post-test data were tabulated in an Excel sheet and data were analysed. Statistical analysis was performed using SPSS 20.0 and MS Excel 2019. Descriptive data were presented as mean ± SD and percentages, data were tabulated and graphically represented. Student's paired t-test and Chi-square test were utilised to compare means of pre-test and post-test. Fisher exact test was used for assessment of DOPS. For statistical analysis, P < 0.05 was considered to be statistically significant.

  Results Top

A total of 190 residents from six clinical specialties involved in patient care of suspected/confirmed COVID patients successfully completed training on VLS within 3 months. Data obtained from correct and completed pre-test and post-test values were analysed. Data from 4 participants were incomplete and hence these were excluded from the final analysis. Among the 186 trainees included in the study, 73 residents belonged to the anaesthesia subspecialty [Figure 1]. Overall mean pre-test scores were found to be 6.16 ± 1.79 which improved to 7.21 ± 2.02 in post-test assessment and this improvement in knowledge was found to be statistically significant with a P < 0.0001 as depicted in [Figure 2]. On comparison of pre-test and post-test scores of residents (Junior and Senior Residents) improvement in knowledge was found to be statistically significant in both groups [Table 3]. Statistically significant specialty-wise changes in the scores were not seen with Senior Residents in Anaesthesiology and Emergency Medicine and Junior and Senior Residents in ENT (P > 0.05) [Table 4]. Comparison of scores between anaesthesiology and other specialties did not reveal any statistically significant difference (P > 0.05). Overall improvement in scores was observed amongst medical and surgical disciplines [Table 5].
Figure 1: Number of participants from various clinical specialties

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Figure 2: Box-and-whisker plot showing pre-test vs post test scores (n = 186)

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Table 3: Comparison of pre-test and post-test scores obtained by junior residents and senior residents

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Table 4: Mean scores of pre-test versus post-test of senior and junior residents

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Table 5: Comparison of pre-test and post-test scores obtained by residents of Medical and Surgical specialities

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Skill assessment through DOPS revealed that 72% of participants performed exceedingly well while 3% scored borderline [Figure 3]. On analysis of performance based on each criterion, it was observed that despite the ongoing COVID-19 pandemic, close to 16% of the residents forgot to don PPE before starting intubation. Subgroup analysis revealed that Anaesthesiology, ENT and Paediatric residents remembered to don PPE before proceeding for intubation, while residents from other specialties (mainly Medicine, Surgery and Emergency Medicine) forgot to don PPE. The difference was found to be statistically significant [Table 6].
Figure 3: Scores obtained by trainees for skill attained through DOPS assessment

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Table 6: Donning of personal protective equipment prior to intubation

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Skill assessment during OSCE revealed that selection of the appropriate device was successfully performed by 95% of the trainees (n = 181) across all specialties. Almost similar results were observed for the sections pertaining to attachment of the device, switching on the VL and checking of the ETT. Residents from other specialties were able to hold the laryngoscope properly following the training program. Difference in the score for correctly holding laryngoscope by nonanaesthesia residents as compared to anaesthesiology residents was not found to be statistically significant (P > 0.05).

The technical skill of laryngoscopy and intubation was assessed through OSCE performance on criteria such as insertion of VL in the midline, visualisation of epiglottis and glottis, as well as the number of attempts for successful intubation [Table 2]. Anaesthesiology residents performed significantly better than residents from other specialties [Table 2]. Criteria such as stabilising the ETT after intubation and inflating the tracheal cuff were successfully performed by all the residents. Approximately half of the nonanaesthesia residents could pass ETT correctly only in the second attempt.

Workshop feedback obtained from the trainees on a 3-point Likert scale revealed that 83% were satisfied with the level of training and demonstration; 90.4% of the respondents felt confident in performing VL at the end of this training; 92.3% of the trainees believed that the interactive lecture and hands-on practice sessions were the most beneficial aspects of the training programme.

  Discussion Top

VLs have been widely used in patients with difficult airways or as a rescue device for failed intubation.[10] Primarily used by the anaesthesiologist for the management of a difficult airway, the VL has slowly gained importance as a device facilitating intubation by nonanaesthesiologists, especially in the ICU and Emergency Department. The Difficult Airway Society brought out recommendations in 2018 that in all ICUs, VL should be made available for it to be used during for the first attempt in situations that may pose a difficult airway.[8],[11] The novel coronavirus infection in 2020 created a unique problem of increased exposure to aerosol laden with highly infectious viral particles during the process of intubation. Manoeuvres were tried to decrease the exposed viral load or containment of infection with intubation box and VL with varying degree of success.[12],[13] The experience of Ponnappan et al. with the intubation box was quite discouraging as they documented an increase number of attempts for successful intubation resulting in a longer duration of contact between the patient and physician.[12]

Evidence in the literature highlights the advantage of VL in a challenging airway situation. These include better laryngeal view, higher first-pass success rate and lower rates of the need for manipulation.[14],[15] In COVID-19 patients, the time for securing the airway is crucial. In addition, adequate distance between the physician intubating and the patient should be maintained during the process of intubation to reduce the risk of exposure to the virus-laden aerosol. Both these could be satisfactorily achieved with VL-aided intubation.[16],[17]

Imparting knowledge and skills necessary for the prevention and treatment of disease to persons seeking to become physicians forms the core of medical education. The combination of involvement to interdisciplinary courses, clinical experience and knowledge updates requires frequent modification in the curriculum to prepare students for better understanding and acceptability to current and future trends in the field.[18] Bedside teaching has been the traditional cornerstone of medical education. Implementing social distancing and online mode of classes as well as small group teaching has become a norm during COVID times.[19]

Imparting knowledge and training in such a time to grown-up adults needed us to incorporate the basics of adult learning[20],[21] as well as introduce innovations for getting our message across. We tried to address this situation in the following order-relevance of teaching (COVID era), setting (Department of Medical Education, simulation-based), teaching methodology (small group, safe environment, didactic lecture followed by demonstration, actual experience of using the device and then debriefing).

In academic medical institute settings, life-saving experiences narrated by teachers, seniors, or peers is a great motivator for learning. The use of simulators for teaching not only helps by recreating difficult scenarios but also allows re-enactment of the same scenario repeatedly.[22] Debriefing sessions at the end of each simulation helped the trainees to understand their shortcomings and correct them for the future. The trainees were encouraged to ask questions throughout the training and were involved in active discussions. Studies have shown that group discussion-based approaches help in adding new dimensions to acquiring new skills by adding purpose and motivation.[23] Simulation-based real-life scenarios helped in building confidence for real-life application of acquired knowledge and skills. This could be gauged by our finding of 90.4% of the respondents feeling confident in performing VL at the end of this training.

A major reason for the lack of knowledge and skill among the residents for VL was limited availability of the equipment outside the operation room. The purpose of our training was to enable the participants with skills and desirable knowledge with hands-on practice and encourage the use of VL for COVID intubations. The low mean pre-test score in our cohort emphasised the lack of knowledge amongst the residents. The benefits of the training to the residents were evident from the improved post-test scores. The improved knowledge could be attributed to a comprehensively designed course content and hands-on practice sessions. This notion is strengthened by the feedback received that demonstrated 92.3% of respondents found the course content and hands-on practice to be the most useful part of the program. Couto et al. highlighted the role of simulation-based training for videolaryngoscopy.[24] Delson et al. conducted a similar simulation-based study and compared the intubation time in pre-test and post-test and found that the time considerably reduced after post-test and skills were retained with quicker successful action.[25] Such rapid skill-based training for capacity development during the COVID-19 pandemic was achievable due to the availability of skilled trainers. Our training program gave hands-on experience to 190 participants within 3 months. Dagli et al. and Komasawa et al. documented that the skill of direct laryngoscopy is essential for the successful acquisition of skill in indirect laryngoscopy [videolaryngoscopy].[26],[27] Before starting VL training, we ensured that participants had learnt the skill of direct laryngoscopy and airway management protocols in COVID-19 cases.

Lack of airway manipulation and application of less force makes VL an easier laryngoscopic technique for use by novice airway managers. This makes it a modality which is easier to learn and perfect even for a nonexpert.[28] Similar results were noted in our study, where the DOPS assessment revealed excellent scores amongst 70% of the trainees. Trainees across all specialties were able to attach the device, insert it properly in the midline, achieve a good view of the cords and intubate the airway manikin during skills assessment.

It has been documented that for performance-based assessments, an appropriate tool would be Mini-Clinical Evaluation Exercise (mini-CEX) and DOPS assessment as learners seem to comprehend better with these evaluation tools.[29] We used a prevalidated checklist in DOPS assessment for maintaining objectivity and uniformity. DOPS assessment is a feasible, valid and reliable tool for simulation-based evaluation.[30]

Even though laryngoscopy is a part of training in anaesthesiology, the results of our study revealed that residents from across other specialties were enabled with skills of videolaryngoscopy. The findings of our study reflect that given an easy learning curve for VL, residents across all specialties would, with proper training, be able to provide expert airway management at the time of emergency.

Limitation of the study

We could not obtain follow up data and progress of the participants.

  Conclusion Top

A well-structured simulation-based training on videolaryngoscopy was effective in imparting indirect airway management skills to residents of various clinical specialties. Simulation-based fast-tracked training on VL proved to be an efficient method to train a large number of clinicians within a limited period. Videolaryngoscopy training may be included as an entrustable professional activity for residents of all clinical specialties as a step towards capacity building which may not only prove useful at the time of emergency but will translate as improved care and safety not only to the patient but also to the caregiver.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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