AWAKE TRACHEAL INTUBATION 2
Awake Tracheal Intubation versus Post-induction Video Laryngoscopy as the Primary Attempt to Secure a known Difficult Airway
Student registered nurse anesthetists (SRNA) undergo specialized training to manage patients with unanticipated airway difficulties or known difficult airways. To accomplish this, they are actively involved in airway simulation techniques to improve knowledge and skills in managing complex airway problems quickly and definitively. These techniques may include using alternative airway devices, invasive surgical airway procedures, or advanced airway management techniques such as fiberoptic bronchoscopy (Maurya et al., 2024). Performing tracheal intubation is an essential skill for managing airways during general anesthesia. This procedure can be conducted in various ways, either post-induction or while the patient is awake. However, performing tracheal intubation while the patient is awake can be a complex process that demands meticulous attention to detail. It involves placing a tracheal tube in an awake, spontaneously breathing patient, typically using flexible fiberoptic bronchoscopy or video laryngoscopy, providing local airway anesthesia, or administering systemic sedation (Law et al., 2023).
Awake Tracheal Intubation (ATI) is a highly effective method and gold standard for managing difficult airways in adults, which occurs in approximately 5.8% of the population. However, despite the effectiveness, post-induction video-assisted laryngoscopy appears to be the primary method anesthesia providers and students use to secure the difficult airway (Ahmad et al., 2019). Law et al. 2023 reported a 50% decline in the incidence of awake tracheal intubation in anesthesia practice in patients with difficult and failed tracheal intubation. This is concerning as the limited use of ATI for managing the difficult airway could potentially reduce opportunities for anesthesia professionals and students to develop and maintain their skill sets (Law et al., 2023). Additionally, when a patient’s airway poses a challenge, it can lead to severe complications like brain damage, cardiopulmonary arrest, airway damage, dental injuries, or even death (Apfelbaum et al., 2022).
Difficult airways are a significant concern that affects a small portion of the population, with an incidence ranging from 0.5 to 2%. However, patients undergoing ear, nose, and throat surgery face a higher risk, which can increase to 8-10%. Individuals with airway tumors are at even greater risk, with a prevalence as high as 28%. Glottic cancer is the most frequently encountered type of airway tumor, accounting for 50-60% of all cases (Espinosa et al., 2022). In pediatric patients who undergo surgery, difficulty with intubation is a common occurrence, with a prevalence rate of 19.7%. Respiratory issues resulting from the difficulty of intubation contribute to 17% of all anesthesia-related complications (Amaha et al., 2021). Additionally, almost 28% of all deaths related to anesthesia are due to difficulties encountered during intubation or ventilation (Amaha et al., 2021). Therefore, anesthesia providers must implement effective airway management procedures and techniques to ensure safe and effective airway management. Ensuring competence in applying theoretical knowledge and practical airway techniques can be achieved via airway workshops, simulation, and regular hands-on practice simulation, which are vital for student anesthetists. Therefore, for my DNP project, I would like to assess the effectiveness of simulation in increasing SRNA confidence in performing awake tracheal intubation as the initial approach in securing difficult airways compared to post-induction video-assisted laryngoscopy.
The difficult airway algorithm emphasizes the importance of time management and minimizing the number of attempts at different airway techniques and devices to reduce the risk of adverse events during airway management. These guidelines aim to streamline airway management for patients with difficult airways, increase the success rate of initial attempts, enhance patient safety, and reduce the likelihood of adverse outcomes (Apfelbaum et al., 2022). Despite ATI being the gold standard for difficult airways, the post-induction video-assisted laryngoscopy strategy is highly preferred and utilized. Also, it is the frequent choice among CRNAs, which has implications for maintaining competence in performing ATI (Law et al., 2023). Therefore, improving awareness, skillset, and understanding of ATI among SRNAs can enhance patient outcomes and ensure safer airway management in patients with difficult airways. Participating in simulation and complex airway workshops is ideal for maintaining competence and refining practice skills (Ahmad et al., 2019).
Hence, the objective of this project is to address the PICOT question: Does simulation training prove helpful in enhancing the awareness and confidence of SRNA in performing awake tracheal intubation as the primary method to secure a known difficult airway, as opposed to post-induction video-assisted laryngoscopy during the second year of their program?
Process Framework
This project aims to evaluate how deliberate practice, simulation technology, and educational sessions can improve the clinical competence and confidence of CRNA and SRNA while performing awake fiberoptic intubation in patients with a known difficult airway. The ACE Star Model of Knowledge Transformation is an asset in translating research into practice. It provides a clear understanding of how we can use specific types of knowledge, such as systematic reviews and clinical practice guidelines, to successfully apply research findings in practice. This model is used to gain insights into the cycle, nature, and characteristics of knowledge used in various phases of Evidence-Based Practice (EBP) (Melnyk & Fineout-Overholt, 2023). Also, the Star Model provides a comprehensive framework that guides the conversion of knowledge into evidence-based practices. By emphasizing the integration of research evidence, clinical expertise, and patient preferences, the model facilitates the creation of effective and patient-centered healthcare solutions (Melnyk & Fineout-Overholt, 2023, p. 508).
To effectively implement simulation training, the complex airway algorithm must be transformed from a clinical practice guideline to an evidence-based airway intervention that can significantly influence anesthesia practice patterns (Melnyk & Fineout-Overholt, 2023, p. 509). Firstly, meetings and collaborative sessions will be held with the project team, which includes the faculty advisor, the CRNA faculty, and the clinical CRNA at the organization. During these sessions, crucial aspects of the simulation will be discussed, such as the desired outcomes, the target audience, and the methodology for conducting the simulation. A clinical scenario will be created, incorporating information on a patient with known difficult airways. The scenario will be meticulously designed, considering the patient’s medical history, current health status, and the preferences of the anesthesia providers involved in the simulation. The goal is to create a highly realistic and engaging situation that simulates the challenges of anesthesia practice in the most accurate way possible. Next, communication will be established with the simulation lab manager to schedule an appropriate time for the simulation. Additionally, the simulation lab manager will help choose a difficult airway manikin best suited for the simulation and obtain all the necessary equipment required to run the simulation successfully. The PICOT questions and simulation objectives will also be reviewed during planning.
The educational approach involves various techniques to promote awareness and adherence to the difficult airway algorithm. This includes a simulation, survey questions, a brief refresher video on awake fiberoptic intubation techniques, and an evaluation and feedback system. The goal is to determine the effectiveness of the simulation in increasing awareness and adherence to the algorithm and assess whether interventions influence the decision to perform awake tracheal intubation versus post-induction video-assisted laryngoscopy in patients with a difficult airway. The simulation exercise will be conducted at the Murray State University School of Nursing simulation center, and the approach will be implemented in the Baptist Health Deaconess operating rooms in Madisonville, Kentucky. The anesthesia providers will be updated on the difficult airway algorithm and encouraged to participate in awake tracheal intubation as the primary choice for patients with known difficult airways.
Literature Review and Synthesis
Purpose
It has been established that most CRNAs prefer post-induction intubation as their first-choice technique in patients with known difficult airways. However, awake tracheal intubation is considered the gold standard when managing a patient with a known difficult airway. Therefore, this project’s literature review explores the factors influencing SRNA’s decision to perform awake tracheal intubation or post-induction video-assisted laryngoscopy in patients with a difficult airway and also assessing the effectiveness of simulation in increasing SRNA confidence in performing awake tracheal intubation as the initial approach in securing a known difficult airway compared to post-induction video-assisted laryngoscopy.
The findings of this literature review and synthesis will be used to implement strategies and interventions to enhance and improve the skill and confidence of anesthesia providers when performing awake tracheal intubation in patients with a known difficult airway.
Design
While conducting the literature review, a comprehensive analysis of the existing literature was performed to identify relevant evidence supporting the PICOT question. During the review process, various inclusion and exclusion criteria were utilized to ensure that the evidence gathered was relevant and reliable. The inclusion criteria involved literature published within the last five years, full-text, peer-reviewed studies, articles published by credible organizations, and literature from nursing and other related medical fields published in English. Online databases were used to gather evidence, including the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, Google Scholar, and PubMed. Keywords used in the search strategy included “difficult intubation,” “awake intubation,” “video-assisted laryngoscopy and “fiber-optic bronchoscopy.”
Sample and Setting
The research highlights the expertise of Certified Registered Nurse Anesthetists (CRNAs) practicing at Baptist Health Deaconess in Madisonville, Kentucky, and the efforts to train junior students in the Nurse Anesthetist program at Murray State University. The focus is on the skills of CRNAs in airway management and specialized procedures such as awake fiberoptic intubation, which enables them to handle airway management challenges efficiently. Additionally, the Student Registered Nurse Anesthetists (SRNAs) training in airway management skills and procedures ensures they are well-equipped to provide optimal care to patients with a known difficult airway.
Interventions
The intervention in this project involves assessing the knowledge and awareness of CRNAs and SRNAs regarding the difficult airway algorithm. Also, an awake tracheal intubation simulation session will be conducted to improve practical skillset and maintain competence. Enhancing the awareness, skillset, and understanding of ATI among CRNAs and SRNAs can improve patient outcomes and ensure safer airway management for patients with difficult airways. Additionally, the project will analyze provider preferences and patient factors influencing the choice of awake versus post-induction intubation.
Results
Performing first-pass intubation in patients with known difficult airways requires careful consideration of several factors. These include the choice of laryngoscopy device, the skill level of the anesthesia provider, and their clinical judgment (Wong et al., 2019). In a study conducted by Law et al., 2023, it was found that awake tracheal intubation can be a complex procedure, but it boasts an impressive success rate of 98.4%. The first-attempt success rate is 82.1%, and the complication rate is only 1-2%. Using a fiberoptic bronchoscope for awake tracheal intubation was significantly more successful than using a video laryngoscope. Also, it is essential to reduce gag and cough reflexes using local anesthetics, ensure appropriate levels of anxiolysis or sedation through coaching and pharmacology, and maintain patient cooperation to ensure successful intubation in difficult airway (Wong et al., 2019). A research study conducted by Zhang et al., 2023 found that using a video laryngoscope resulted in a success rate of 96.6% in post-induction tracheal intubation in patients with a difficult airway. However, if there are multiple failed post-induction tracheal intubation attempts and a “cannot intubate, cannot ventilate” situation arises, an invasive approach to airway management may be necessary, which could increase morbidity and mortality (Apfelbaum et al., 2022, p. 39). Conversely, suppose an anesthesia provider cannot obtain a patent airway in an awake patient and other options fail. In that case, the procedure can be aborted with minimal complications as patient spontaneous breathing efforts are preserved. The frequency of awake intubation (ATI) used for managing the complex airway is limited, and this could potentially reduce opportunities for anesthesia professionals and students to develop and maintain their skills (Law et al., 2023).
Value of the Evidence
This paper presents sufficient evidence to support the conclusion that awake tracheal intubation (ATI) is highly effective and should be the first technique chosen when predictors of difficult airway management are present. ATI is a first-line approach in airway management for known difficult airways due to its high success rate and low-risk profile (Ahmad et al., 2019). Moreover, it is crucial for anesthesia providers to use appropriate equipment and anesthesia techniques for challenging airways to significantly decrease the morbidity and mortality risks associated with tracheal intubation (Amaha et al., 2021).
Anesthesia providers can determine the most effective approach for managing difficult airways using a difficult airway algorithm, patient assessment, and personal preferences. However, the algorithm offers valuable guidelines for CRNAs to prepare, make informed decisions, and conduct endotracheal intubation safely. Likewise, it is crucial to maintain anesthesia providers’ competency and skill level to ensure successful and safe procedures (Apfelbaum et al., 2022).
Agency Description
After discussion with the CRNA faculty, the simulation for my project will be held at the Murray State University simulation lab located at Murray-Calloway County Hospital. The simulation center offers SRNAs the opportunity to practice challenging airway scenarios, including awake fiberoptic intubation, which they may encounter in clinical settings. The facility was designed to provide graduate-level nurses with the necessary education to deliver high-quality care and to be professionally trained to address the complex healthcare needs of the population. The simulation center’s objective is to develop evidence-based simulation experiences that foster the growth of nursing providers in a secure learning environment. This aligns with the project objectives of developing SRNA’s skillsets and competence in awake tracheal intubation. Also, the simulation center is equipped with a high-fidelity manikin, fiberoptic laryngoscope, endotracheal tubes of varying sizes, and simulation drugs, which are essential for the scenario.
The project will be implemented in the operating rooms of Baptist Health Deaconess, Madisonville, Kentucky. The hospital is committed to providing top-notch healthcare services to all patients in a nurturing and compassionate setting. Their care philosophy is based on patient safety, respect, and excellence. This study focuses on SRNAs and CRNAs who provide anesthesia care and airway management for patients with difficult airways.
A vast amount of the cost for this project will be attributed to production time because completing it will require a significant amount of time. The needed materials and equipment are available in the simulation lab and commonly used in Baptist Health’s anesthesia practice. Anesthesia providers are constantly learning and participating in education and training programs for professional development and to comply with the highest standard of anesthesia care. As a result, this project aligns with the SRNA’s training and anesthesia practice for managing difficult airways. It supports the organizational goal of prioritizing patient safety and ensuring the best patient outcome. Time is a constraint for the target population for my project, so careful consideration and communication are essential to ensure the project is done on a day that SRNA is scheduled for simulations and skills. Also, to facilitate the CRNA, I hope to organize a simulation day in a vacant operating room where CRNAs can drop in throughout the day and participate in the session.
Plan
The project team involved in this project includes the Doctor of Nursing Practice faculty, CRNA faculty, and clinical CRNA. The participants for the study include second-year SRNA from the Murray State Nurse Anesthetists program and volunteer CRNA at the Baptist Health Hospital, Madisonville. A brief pre-test survey will be conducted using questions that assess the knowledge of SRNA and CRNA’s awareness of the difficult airway algorithm and competence in performing awake tracheal intubation. As part of the simulation preparation, all participants will watch a short video explaining the technique used in awake fiberoptic intubation in addition to the simulation. The video will cover all necessary aspects of the technique, including the equipment used, the proper positioning of the patient, and the steps involved in the procedure. This ensures that all participants understand the procedure and are well-prepared for the simulation exercise. Participants will be given a scenario of a patient with a known difficult airway. Also, a choice of topical anesthetic with or without intravenous sedation will be discussed to accommodate patient tolerance of the procedure. The decision to use topical or intravenous sedation during awake fiberoptic intubation will be based on the provider’s preference or patient factors such as medical history, allergies, anxiety, and discomfort. This selection will be made considering the prior experience and knowledge of the CRNAs and SRNAs. The goal is to increase anesthesia providers’ knowledge of awake fiberoptic intubation, familiarity with the procedure, and confidence in performing awake tracheal intubation.
Also, a poster will be displayed to highlight the difficult airway algorithm. The algorithm is a systematic approach to managing patients with difficult airways. The poster will provide a detailed algorithm overview, including the steps and rationale behind each step. The aim is to increase awareness of the algorithm among anesthesia providers and encourage its use in clinical practice to improve patient outcomes. The poster will be prominently displayed in a central location and easily accessible. At the end of the simulation, The CRNAs and SRNAs will be instructed to fill out a brief post-test to evaluate confidence level and skill improvement when performing awake fiberoptic intubation. The post-test will be accessible to each participant through a QR code or a printed copy. The project budget is estimated at $200 for posters, printing materials for the post-test, and a summary of the interventions.
Encouraging CRNAs and SRNAs to participate in awake fiberoptic simulation can help them develop their skills in airway management, leading to better patient outcomes. Moreover, by educating anesthesia providers on the intricate steps of the difficult airway algorithm, they can feel more confident in choosing awake tracheal intubation over post-induction video laryngoscopy for patients with known difficult airways. Also, this project will help SRNAs and CRNAs refine their practice skills and maintain competence by participating in future simulation exercises and complex airway workshops focused on performing fiberoptic intubation.
Evaluation Plan
The potential risks associated with decreased use of ATI in difficult airways underscore the importance of ensuring anesthesia providers are adequately prepared to perform awake tracheal intubation. This project aims to promote simulation training to enhance and maintain provider competence in this critical skill. Also, it will increase awareness and adherence to the difficult airway algorithm while exploring factors influencing their decision to perform awake fiberoptic intubation versus post-induction laryngoscopy in patients with a known difficult airway. A detailed qualitative analysis of the pre-and post-test questions will be conducted to measure the impact of the training on the anesthesia provider’s confidence in performing awake tracheal intubation. The analysis will provide insights into the areas where the training has been successful and where further improvement is needed. As part of the quality improvement project, a reassessment of anesthesia provider preference and competence in performing awake tracheal intubation versus post-induction video laryngoscopy in patients with known difficult airways will be conducted six months after the project’s implementation. The reassessment will involve collecting data on the preferences of anesthesia providers and their level of competence in awake tracheal intubation skillset.
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