Learning curve for flexible bronchoscope-guided orotracheal intubation for anesthesiology residents: A cumulative sum analysis

BACKGROUND: Endotracheal intubation with a flexible bronchoscope is a well-recognized airway management technique that anesthesiologists must master. Skill acquisition and knowledge must reach an appropriate level before trainees perform independent practice on patients. There are a paucity of evidence-based outcome measures of trainee competence in performing flexible bronchoscopy. The objectives of this study were to 1) construct a learning curve for flexible bronchoscope-guided orotracheal intubation for anesthesiology residents using the CUSUM method and 2) determine the number of procedures required to achieve proficiency. METHODS: This study included 12 first-year anesthesiology residents with no previous experience with flexible bronchoscopic intubation. Trainees attended theoretical and simulation training and performed flexible bronchoscope-guided orotracheal intubation in adult patients with normal airways under general anesthesia. Number of intubation attempts, intubation success rate, time to intubation, and incidence of dental and mucosal injuries were recorded. The cumulative sum (CUSUM) method was used to evaluate the learning curve of flexible bronchoscope-guided orotracheal intubation. RESULTS: Trainees performed flexible bronchoscope-guided orotracheal intubation on 364 patients. First-attempt intubation success occurred in 317 (87.1%) patients. Second-attempt intubation success occurred in 23 (6.3%) patients. Overall, the flexible bronchoscope-guided orotracheal intubation success rate was 93.4% (range, 85.3% to 100%). The mean number of orotracheal intubation procedures per trainee was 31 ± 5 (range, 23 to 40). All trainees crossed the lower decision boundary (H(0)) after 15.1 ± 5.6 procedures (range, 8 to 25 procedures). There was a significant decrease in median intubation time [39s (IQR: 30, 50) vs. 76s (IQR: 54, 119)] (P < 0.001) after crossing the lower decision boundary (H(0)) compared to before. There were no dental, mucosa, arytenoid or vocal cord trauma events associated with intubation. CONCLUSIONS: Learning curves constructed with CUSUM analysis showed that all trainees (anesthesiologist residents) included in this study achieved competence (intubation success rates ≥ 80%) in flexible bronchoscope-guided orotracheal intubation. Trainees needed to perform 15 (range, 8 to 25) procedures to achieve proficiency. There was wide variability between trainees. TRIAL REGISTRATION: Trial registration: Chinese Clinical Trial Register, ChiCTR 2000032166.