The Problem

Idea Series LogoDifficult airways, including those that are edematous, burned, soiled, or traumatic, pose one of the greatest procedural challenges for emergency physicians. Furthermore, unanticipated difficult airways represent 5-15% of intubations in the ED. Emergency medicine residents gain experience with difficult airways largely through hands-on practice while caring for critically ill patients. The relatively low frequency of complex intubations, however, necessitates an educational model that extends beyond the ED and can be shared with multiple learners.

The Innovation

Through a 2-part educational model, difficult intubations were recorded in real-time using a C-MAC video laryngoscope. The videos were discussed in a one-on-one setting immediately after the intubation, as well as during bi-monthly group reviews with residents and faculty during a conference.

Target Learners

This innovation targets all levels of residents as well as third and fourth-year medical students and is applicable to anyone pursuing a career in emergency medicine, anesthesiology, or critical care.

Materials Needed

Review of difficult airways requires a video laryngoscope with recording capabilities. Maintaining a memory card with adequate storage space requires fairly regular downloading of material. For group discussion, a PowerPoint or Keynote presentation can greatly facilitate learning.

Description of the Innovation

Pre-part 1: Preparing Residents and Faculty

Prior to the introduction of this innovation, a summary of how to record intubations using the C-MAC should be presented to the residents and faculty. Details of when to start and discontinue recording should also be discussed.

Part 1: Recording the Video and Immediate Feedback

On an entirely volunteer basis, residents are encouraged to record intubations using the C-MAC record feature. The intubating resident is encouraged, but not required, to flash his or her name badge in order to identify the clip. Recording is typically started at the beginning of induction or on approach to the mouth. It is discontinued at the end of the intubation. The resident and attending then have the option of reviewing the video immediately for real-time feedback.

Part 2: Group Discussion

On a bi-monthly basis, videos are collected and summarized in a presentation. The presentation can be added to the resident conference curriculum and used to introduce and teach a topic in airway education such as:

  • Delayed sequence intubations
  • Pre-oxygenation and airway adjuncts
  • Intubation of gastrointestinal bleeds
  • Intubation of soiled airways
  • RSI agents, indications, adverse effects, and contraindications
  • Pediatric airway management
  • Airway anatomy and grading systems (Cormack Lehane and Mallampati)
  • Awake intubations
  • Intubation of the asthmatic
  • Intubation in the setting of severe metabolic acidosis

After the presentation, selected videos are reviewed in open group discussion with opportunity for comment by residents and faculty. If a video was tagged with a resident’s name badge, the resident is encouraged to provide the clinical scenario that precipitated the intubation.

Lessons Learned

In our residency, the implementation of this airway curriculum has been successful. Over 84% of surveyed residents agree or strongly agree that peer reviewed airway is useful. Our program incentivized recording intubations by applauding the “smoothest tube,” “most creative” and “most challenging” airways. This healthy competition boosted enthusiasm for the innovation.

Implementation at our program has resulted in the development of over 2 years of recorded examples of difficult airways. This has led to the creation of a FOAMed resource based on these concepts and style of learning, entitled

Several pearls were also identified to maximize success:

  • Identify individuals who know the C-MAC device well and can troubleshoot if the video is not recording, so that they can assist in the event of a technical difficulty.
  • Encourage residents to stop recording immediately after the intubation in order to avoid filling the memory card with unnecessary footage.
  • Remind the residents that they do not need to self-identify and/or can be de-identified. This is important as some residents will feel uncomfortable being critiqued in a group format, and often the intubations chosen for review are the ones that did not go smoothly.

Theory Behind the Innovation

A difficult airway is relatively rare, hard to replicate, and challenging to teach outside of the instance in which it occurs. Multiple modalities exist to help teach and demonstrate these difficult airways, and video review functions as an additional high fidelity modality. The 2 parts of this educational model provide immediate and direct feedback after intubation, as well as the opportunity for regular peer review. This innovation provides emergency physicians with an opportunity to learn from others’ experience with difficult airways, including cases that one may not have encountered previously. Our model provides the option of anonymous or self-identified review. Subsequent discussion and review of videos, supplemented with targeted instruction, offer an additional modality of experiential learning.

Read more about the IDEA Series.

Terren Trott, MD

Terren Trott, MD

Associate Professor
Department of Emergency Medicine
University of Kentucky
Lexington, KY
Terren Trott, MD


Emergency Medicine + Ultrasound + Critical Care Physician + Airway Enthusiast. Editor for and