1. Do You See Anything That You Recognize: Teaching Novice Student Registered Nurse Anesthetists to Intubate Using the GlideScope Stephanie K. McHenry, CRNA, MSN, ARNP

2. 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 (A youb, 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)

3. 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.

4. 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)

5. 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)

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

7. Type of Video Laryngoscope Used in Research Studies

8. Teaching Module Intubation 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

9. 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

10. 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.

11. 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.