Curriculum
Rotation Objectives and Educational Purposes:
The ability to place a secure airway in myriad clinical situations is a necessary skill of critical care physicians and is an ACGME requirement of fellowship training. Airway management in the ICU can be complicated due to many factors, and the incidence of failed airways in the ICU is much higher than that of elective intubations performed in the OR. Those factors that can complicate stabilization of the airway in the ICU warrant standardization of intubation in the ICU.
Learning the skills associated with airway management in the controlled setting of the operating room under direct supervision by anesthesiologists will facilitate the acquisition of the required skill set. Our aim is that physician trainees will learn the fundamentals of airway examination, the proper preparation for airway manipulation, and the technique of successful intubation to minimize patient complications.
Under the instruction of anesthesiology staff, PCCM and CCM fellows will develop the skill of successful airway placement during this two-week rotation.
The goals of this rotation for PCCM and CCM fellows are:
To evaluate airway anatomy and relevant patient factors
Approaches to airway management, including the difficult airway
Understanding Rapid Sequence Intubation (not commonly practiced in the ICU)
Rotation Structure
Monday Friday
7am 3pm with flexibility of hours depending on operating room schedule
No nights, no weekends
Fellow will work with Staff Anesthesiologist and/or CRNA who will directly supervise each procedure
Competency Specific Rotation Objectives
Medical Knowledge, Patient Care
Understanding the fundamentals of airway assessment
a. Airway anatomy
b. Mallampati classification system
c. Limited/unstable neck
2. Reinforcing proper preparation for intubation
BMV, suction, intravascular access, fluids/pressors for hemodynamic support
3. Using the fundamental tools of intubation to successfully perform direct laryngoscopy in a simulated clinical environment.
a. Nasopharyngeal and oropharyngeal airways
b. PEEP valves on BVM
c. Laryngoscope selection (blade type and size)
4. Reinforcing immediate postintubation management
a. Confirmation of correct tracheal intubation
b. Assessing adequacy of oxygenation/ventilation
c. Sedation and analgesia
Assessing the difficult airway by recognizing the clinical factors that complicate ventilation or intubation in obese and non-obese patients
Describing risk factors, physical examination findings, and clinical situations associated with a difficult airway.
Demonstrating effective management of the simulated patient with a difficult airway.
Difficult ventilation- due to anatomic and functional factors (face and upper airway, chest-wall mechanics, or lower airways)
Difficult intubation – oropharyngeal obstruction, airway stents
Understanding pharmacology of medications and important side effects for proper selection to facilitate laryngoscopy, augment the response to intubation and reduce the risk of aspiration
Demonstrating a systematic approach to patient, equipment, and drug preparation prior to intubation:
Preinduction agents such as lidocaine, opioids
NMBA differences between depolarizing and non-depolarizing agents, their action, onset, clearance, and contraindications
Induction agents etomidate, propofol
d. Sedatives
Familiarizing fellows with advanced tools to facilitate intubation and patient selection for alternative intubation approaches
Classifying the various types of equipment used in the management of the patient with a difficult airway and understand their potential uses and limitations:
Gum elastic bougie
LMA
Combitube
Videoscope
Technique of fiberoptic intubation
Interpersonal and Communication Skills, Professionalism
Demonstrating effective communication skills with patients, families, and colleagues
Modeling professional behavior for the management team during airway emergencies
Patient Care, Systems Based Practice
Using crisis resource management principles to effectively utilize an airway management team, maximizing success and patient safety during intubation
Demonstrating commitment to patient advocacy and safety in airway management
Practice Based Learning and Improvement
1. Debrief and reviewing cases for process improvement with the airway management team
Teaching this evidence based skill set to trainees across disciplines
Teaching Methods
Supervised patient care
Fellows will learn these skills under the direct supervision of a staff anesthesiologist and/or CRNA in the operating room
Study resources
Clinical Procedures in Emergency Medicine, Fifth Edition (2010)
Basic airway management and decisionmaking
Tracheal intubation
Pharmacologic adjuncts to intubation
Clinical practice and risk factors for immediate complications of
endotracheal intubation in the intensive care unit: A prospective,
multiple-center study Crit Care Med 2006 Vol. 34, No. 9; 2355-2361
Evaluation
Evaluation of fellow performance
Formative feedback with procedural checklist for each intubation
Summative feedback at end of rotation