How big of a deal is poor airway training in fellowship?

[cavitarynodule]

A lot of programs seem to have minimal airway training and fellows say they will graduate without proficiency. To me an intensivist who can't manage airways and intubate is like a pulmonologist who can't bronch so I'm very surprised to find this is accepted and seems to be ok by ACGME rules.

So, I'm wondering what people think about if this is indeed something that should heavily influence fellowship choice. Obviously if you are sold on a research career you won't need it but say you miss out on grants - does not having this training basically make you trapped in academics and unable to take any community position?

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[tartesos]

It's not a big deal if you won't be Intubating...


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[tartesos]

There's a difficult airway course in atl I've heard great things about. I didn't feel like I needed it since we did/supervised all the Intubations outside of an or at my shop, but I would have taken it if I felt I needed it.


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[cavitarynodule]

It's not a big deal if you won't be Intubating...

Well my question basically is getting at what is the prevalence of community or even university positions that expect you to intubate as pccm intensivist? Does not having this ability severely limit your job prospects?

 

[CCM-MD]

I wouldn't join a program that has bad airway training. You want to be able to get ~50 intubations - theres an old study that suggests this is where success plateaus at ~90-95%. If you have one good anesthesia month and do some non-OR intubations periodically throughout fellowship, 50 shouldn't be hard to reach. I would take a difficult airway course also - we had one integrated in our fellowship and it was helpful.

Honestly, video laryngoscopy has changed the world - there's hospitals where RTs intubate! The more important thing to do is how to manage when things go wrong --> being able to BMV well, put in an LMA, and when to consider a surgical airway.

If you don't want to intubate at all, it probably won't limit job prospects because the demand is high and market is strong currently. Are there intensivist gigs that require you to intubate/own the airway? Yes. Are there jobs that don't require you to do airway? Also yes.

 

[tartesos]

Well my question basically is getting at what is the prevalence of community or even university positions that expect you to intubate as pccm intensivist? Does not having this ability severely limit your job prospects?

In most places it is expected for the intensivist to intubate most patients out of the or. Anything else is an exception, not a rule.
One thing to remember is Anything is negotiable.


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[jdh71]

In most places it is expected for the intensivist to intubate most patients out of the or. Anything else is an exception, not a rule.
One thing to remember is Anything is negotiable.


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Sort of. I would say that's the "expectation" but not a hard and fast rule. Most places figure you will do most of your intubations. Most places do not assume you are at an anesthesia level of airway management. I still ask them to do a few tubes a year as long as things aren't super urgent/emergent. I only use video laryngoscopy. I always paralyze. I only take one crack at it before asking for help.

To the OP I wouldn't let airway be your top consideration but any place that isn't giving you any or doesn't have a good clean plan to get you to 30-50 during your three years might be something that would put them lower on your list.

 

[tartesos]

Sort of. I would say that's the "expectation" but not a hard and fast rule. Most places figure you will do most of your intubations. Most places do not assume you are at an anesthesia level of airway management. I still ask them to do a few tubes a year as long as things aren't super urgent/emergent. I only use video laryngoscopy. I always paralyze. I only take one crack at it before asking for help.

To the OP I wouldn't let airway be your top consideration but any place that isn't giving you any or doesn't have a good clean plan to get you to 30-50 during your three years might be something that would put them lower on your list.

I've gotten lazy, I intubate quite often and paralyze like 20% of the cases. Use direct laryng 80% of the time and I am getting that tube down thst throat so help me God as long as it takes! ( been lucky but after the first try you can tell if you need help or not based on the airway. )


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[jdh71]

I've gotten lazy, I intubate quite often and paralyze like 20% of the cases. Use direct laryng 80% of the time and I am getting that tube down thst throat so help me God as long as it takes! ( been lucky but after the first try you can tell if you need help or not based on the airway. )


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I don't know if that is "lazy". Everyone needs to have a stable strategy in how they approach their intubations and then doing it the same way very time. For instance, I'm used to bronchs, and screens, and looking at the airway like that and I feel a lot more comfortable with VL going into an airway because of that. Everyone needs to strategize what will be the best first crack shot for them and for some people that will mean DL. I think the evidence for paralyzing is good relatively speaking and improves first pass chance, but understand the rationale given by those that regularly don't.

One trick (I picked up from Scott Weingart's podcast) I use a lot in the ICU with patients who have nice sats on bipap but are otherwise pretty ****ty because they are ICU patients, is that I do a slow ketamine induction ON the bipap as long as sats are really good and it's not a sick head. I give 1-2 of versed and watch the BP, and I'll give some push dose phenyl (100mcg/ml) if the BP starts to go soft on me (unless bradycardic then, I'll make an epi push with pharmacy). I'll give the ketamine as two slow pushes which as long as you don't slam it in doesn't slow down their breathing considerably. I position quickly. Then I paralyze, usually with sux, and when breathing efforts stop, off comes the bipap mask, in goes the glide scope and then usually the tube. If it looks like it's going to be a problem, in goes an LMA and I ask for help.

 

[tartesos]

I don't know if that is "lazy". Everyone needs to have a stable strategy in how they approach their intubations and then doing it the same way very time. For instance, I'm used to bronchs, and screens, and looking at the airway like that and I feel a lot more comfortable with VL going into an airway because of that. Everyone needs to strategize what will be the best first crack shot for them and for some people that will mean DL. I think the evidence for paralyzing is good relatively speaking and improves first pass chance, but understand the rationale given by those that regularly don't.

One trick (I picked up from Scott Weingart's podcast) I use a lot in the ICU with patients who have nice sats on bipap but are otherwise pretty ****ty because they are ICU patients, is that I do a slow ketamine induction ON the bipap as long as sats are really good and it's not a sick head. I give 1-2 of versed and watch the BP, and I'll give some push dose phenyl (100mcg/ml) if the BP starts to go soft on me (unless bradycardic then, I'll make an epi push with pharmacy). I'll give the ketamine as two slow pushes which as long as you don't slam it in doesn't slow down their breathing considerably. I position quickly. Then I paralyze, usually with sux, and when breathing efforts stop, off comes the bipap mask, in goes the glide scope and then usually the tube. If it looks like it's going to be a problem, in goes an LMA and I ask for help.

Rsi is the tits.
Paralyzing improves first pass rates dramatically( and it makes it easy) but I hope I don't jinx myself, I've gotten lucky and I'm confident on my skills but one thing I've learned is to never take an intubation lightly, I have my bugie, glidescope and lma( we have a difficult airway box that has fun stuff and Rt hulls it around to all tubings) at arms reach at all times, it wards off evil spirits just like the crash cart in front of a room, it works!
Planning goes a long way and you need to learn to analyze anatomy quickly.


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[Colorado outliers]

Rsi is the tits.
Paralyzing improves first pass rates dramatically( and it makes it easy) but I hope I don't jinx myself, I've gotten lucky and I'm confident on my skills but one thing I've learned is to never take an intubation lightly, I have my bugie, glidescope and lma( we have a difficult airway box that has fun stuff and Rt hulls it around to all tubings) at arms reach at all times, it wards off evil spirits just like the crash cart in front of a room, it works!
Planning goes a long way and you need to learn to analyze anatomy quickly.]


Couldn't agree more. I paralyze (ROC 1mg/kg) nearly every patient for intubation if possible. Bougie and C-MAC are key, as well as LMA, for backup. There is almost nobody you cannot intubate with a video laryngoscope plus a bougie.
If I suspect the airway will be really difficult, we get the bronch cart ready and scope loaded with an ET tube ahead of time.
Don't use ketamine much personally but others have used it w/ great results, sometimes a Propofol/ketamine cocktail (EM style).

Also agree with not taking intubations lightly - I got burned once and had to call anesthesia to intubate...I am much more cautious now than when I started.