Training in placement of the left-sided double-lumen tube among non-thoracic anaesthesiologists: intubation model simulator versus computer-based digital video disc, a randomised controlled trial.
ABSTRACT To compare the effectiveness of training with an airway model simulator versus digital video disc (DVD)-based instruction in placement of double-lumen endotracheal (DLT) tubes by anaesthesiologists with limited thoracic experience.
Single academic centre parallel randomised controlled trial with computer-generated random allocation.
Sixty patients undergoing elective thoracic or oesophageal surgeries requiring one-lung ventilation. Twenty-seven non-thoracic anaesthesiologists were randomised to place a DLT.
DLT placement instruction by an interactive airway simulator or computer-based DVD training. The main outcome measure was successful DLT placement.
Twenty-seven anaesthesiologists were randomised to one of the two intervention groups. Sixty consecutive patients were assigned to a randomised anaesthesiologist (n = 30 in each group). Participants failed to correctly place or position the DLT tubes in 14 of 60 patients (failure rate of 23%). There was no difference in the probability of satisfactory placement or time for positioning of the DLT between the training groups; 80.5% (95% confidence interval 58.2-96.2%) of tubes were successfully placed following intubation model simulator training versus 73.6% (95% confidence interval 49.8-88.5%) in the DVD group (P = 0.378).
Both teaching methods had similar outcomes for placement of DLTs by anaesthesiologists with limited thoracic anaesthesia experience. Both groups performed better than individuals in our prior study. Therefore, these methods should be considered when training anaesthesiologists to successfully place DLTs.
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ABSTRACT: The authors have defined the margin of safety in positioning a double-lumen tube as the length of tracheobronchial tree over which it may be moved or positioned without obstructing a conducting airway. The purpose of this study was to measure the margin of safety in positioning three modern double-lumen tubes (Mallinkrodt [Broncho-Cath], Rusch [Endobronchial tubes], and Sheridan [Broncho-Trach]). The margin of safety in positioning a: 1) left-sided double-lumen tube (all manufacturers) is the length of the left mainstem bronchus minus the length from the proximal margin of the left cuff to left lumen tip; 2) Mallinkrodt right-sided double-lumen tube is the length of the right mainstem bronchus minus the length of the right cuff; and 3) Rusch right-sided double-lumen tube is the length of the right upper lobe ventilation slot minus the diameter of the right upper lobe. The length of the right and left mainstem bronchi were measured by in vivo fiberoptic bronchoscopy (n = 69), in fresh cadavers (n = 42), and in lung casts (n = 55), and the diameter of the right upper lobe bronchus was measured in lung casts (n = 55). The average +/- SD male left and right mainstem bronchial lengths were 49 +/- 8 and 19 +/- 6 mm, respectively, the average +/- SD female left and right mainstem bronchial lengths were 44 +/- 7 and 15 +/- 5 mm, respectively, the average right upper lobe bronchial diameter was 11 mm, the proximal left cuff to left lumen tip distance was 30 mm, the length of the Mallinkrodt right cuff was 10 mm, and the length of the Rusch right upper lobe ventilation slot was 15 mm. The average margin of safety in positioning left-sided double-lumen tubes ranged 16-19 mm for the different manufacturers. The average margin of safety in positioning Mallinkrodt right-sided double-lumen tubes was 8 mm, and the margin of safety in positioning Rusch right-sided double-lumen tubes ranged 1-4 mm, depending on French size. The authors concluded that left-sided double-lumen tubes are much preferable to right-sided double-lumen tubes because they have a much greater positioning margin of safety, and that proper confirmation of proper position of either a left- or right-sided double-lumen tube should be aided by fiberoptic bronchoscopy, because the absolute distances that constitute the margin of safety are extremely small.Anesthesiology 12/1987; 67(5):729-38. · 5.16 Impact Factor
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ABSTRACT: In this study, we compared two different training simulators (the computer screen-based simulator versus the full-scale simulator) with respect to training effectiveness in anesthesia residents. Participants were evaluated in the management of a simulated preprogrammed scenario of anaphylactic shock using two variables: treatment score and diagnosis time. Our results showed that simulators can contribute significantly to the improvement of performance but that learning in treating simulated crisis situations such as anaphylactic shock did not significantly vary between full-scale and computer screen-based simulators. Consequently, the initial decision on whether to use a full-scale or computer screen-based training simulator should be made on the basis of cost and learning objectives rather than on the basis of technical or fidelity criteria. Our results support the contention that screen-based simulators are good devices to acquire technical skills of crisis management. Mannequin-based simulators would probably provide better training for behavioral aspects of crisis management, such as communication, leadership, and interpersonal conflicts, but this was not tested in the current study. IMPLICATIONS: We compared two different training simulators (computer screen-based versus full-scale) for training anesthesia residents to better document the effectiveness of such devices as training tools. This is an important issue, given the extensive use and the high cost of mannequin-based simulators in anesthesiology.Anesthesia & Analgesia 07/2002; 94(6):1560-5, table of contents. · 3.30 Impact Factor
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ABSTRACT: Anesthesia simulators can generate reproducible, standardized clinical scenarios for instruction and evaluation purposes. Valid and reliable simulated scenarios and grading systems must be developed to use simulation for evaluation of anesthesia residents. After obtaining Human Subjects approval at each of the 10 participating institutions, 99 anesthesia residents consented to be videotaped during their management of four simulated scenarios on MedSim or METI mannequin-based anesthesia simulators. Using two different grading forms, two evaluators at each department independently reviewed the videotapes of the subjects from their institution to score the residents' performance. A third evaluator, at an outside institution, reviewed the videotape again. Statistical analysis was performed for construct- and criterion-related validity, internal consistency, interrater reliability, and intersimulator reliability. A single evaluator reviewed all videotapes a fourth time to determine the frequency of certain management errors. Even advanced anesthesia residents nearing completion of their training made numerous management errors; however, construct-related validity of mannequin-based simulator assessment was supported by an overall improvement in simulator scores from CB and CA-1 to CA-2 and CA-3 levels of training. Subjects rated the simulator scenarios as realistic (3.47 out of possible 4), further supporting construct-related validity. Criterion-related validity was supported by moderate correlation of simulator scores with departmental faculty evaluations (0.37-0.41, P < 0.01), ABA written in-training scores (0.44-0.49, < 0.01), and departmental mock oral board scores (0.44-0.47, P < 0.01). Reliability of the simulator assessment was demonstrated by very good internal consistency (alpha = 0.71-0.76) and excellent interrater reliability (correlation = 0.94-0.96; P < 0.01; kappa = 0.81-0.90). There was no significant difference in METI versus MedSim scores for residents in the same year of training. Numerous management errors were identified in this study of anesthesia residents from 10 institutions. Further attention to these problems may benefit residency training since advanced residents continued to make these errors. Evaluation of anesthesia residents using mannequin-based simulators shows promise, adding a new dimension to current assessment methods. Further improvements are necessary in the simulation scenarios and grading criteria before mannequin-based simulation is used for accreditation purposes.Anesthesiology 01/2003; 97(6):1434-44. · 5.16 Impact Factor