Written by Jason Lesnick
Spoon Feed
This retrospective study found increased first pass success (FPS) when EM post-graduate year (PGY) PGY2s, 3s, or 4s intubated patients with Cormack-Lehane grade 3 or 4 airways compared to EM PGY1s. There was no difference in obtained views by PGY after PGY1.
The views don’t change, but you do.
This was a retrospective analysis of 15,435 first attempts at ED intubation from 25 sites in the NEAR (National Emergency Airway Registry) database. The authors estimated adjusted odds ratios (aORs) between PGY and Cormack-Lehane view and the interaction between PGY and Cormack-Lehane view on FPS.
The authors found the aORs for a higher Cormack–Lehane grade did not differ from PGY2 (1.01; 95% CI 0.49 to 2.07), PGY3 (0.92; 0.31 to 2.73), or PGY4 (0.80; 0.31 to 2.04) groups relative to PGY1s. However, for patients with Cormack–Lehane grade 3 or 4, the aORs for FPS were higher for PGY2 (1.80; 95% CI 1.17 to 2.77), PGY3 (2.96; 1.66 to 5.27) and PGY4 (3.10; 1.60 to 6.00) groups relative to PGY1.
There were strong associations between FPS and Cormack-Lehane grade views.
The authors postulate that based on their data, laryngoscopy skills are generally acquired during PGY1, while tube placement skill learning occurs later in training.
How will this change my practice?
I commend the authors for analyzing the two components of endotracheal intubation in this study – laryngoscopy and tube placement – in an attempt to examine why we observe improved FPS with increased training. This study tells me we may have additional room for improvement if we aim to improve tube placement ability earlier in residency and seek additional microskill improvement later on in training to obtain better views during laryngoscopy.
Source
Emergency Medicine Postgraduate Year, Laryngoscopic View, and Endotracheal Tube Placement Success. Ann Emerg Med. 2024 Jul;84(1):11-19. doi: 10.1016/j.annemergmed.2024.03.004. Epub 2024 Apr 19. PMID: 38639674.
Great food for thought when you think about intubation learning curves – learners probably are improving on mostly tube delivery until they plateau, as opposed to just obtaining a view (especially given 60-70% done with VL of some sort)