Department

of Anesthesia,

Massachusetts

General

Sspita:,

Moston,

MA.

AnesthesiokoCgists must be competent

in the technique

intubation

The goal of this stud3 was to test the hypothesis

in airway management.

that an acceptable
tubation

Level of technical

may be acquired

The learning

objectives

patients

intubated
for

were an intubation

*Clinical Fellow in Anesthesia,

setts General Hospital

hlassachu-

with normal

was 1.92

Address reprint requests to Dr. Johnson

at
the Department
of Anesthesia,
Carle Clinic
Association,
602 West University
Avenue,
Urbana,
IL 61801, USA.

0 I989 Butter-worth

344

Publishers

1.45

laryngoscopy

was generated

using logarithmic

of patients

time decreased

and the percent

success

There were no clinically

Ninety-one

had general

fiberoptic
Four

scope;
residents

at least 15 patients

combined.
4.00

or less and greater

ASA phyical

status

anesthesia

and were

the mean (t

SD) time

each. A learning curue

SD) time for i?~~~bation,

to 1.53

+ 0.76

minutes

urith.in

the -mean time was I .51 minutes

on the first attempt at intubation

changes

and in-

patient safety.

The curve showed that the mean ( +

2.91

After the tenth intubation,

important

and

with no prior experience

analysis of the mean (5

from

laryngoscop~l

time of 2 minutes

anatomy

intubated

laryzgvscopy

while maintaining

attempt.

minutes.

I to 15 for all residents

the first 10 intubations.

was greater

in 0, saturation,

than 95Yc.

mean arterial

pressure

of fiberoptic intubation. The results

(MAP), or heart rate (HR) as a consequence
suggest that an acceptable level of technical expertise in fiberoptic
intubation. can
be obtained
patient
sider

Received for publication

November 7, 1988;
revised manuscript
accepted for publication
February
13, 1989.

laryngeal

with fiberoptic

SD) intubation
tAssistant
Professor
in Anaesthesia,
Barvard Medical School; Associate Anesthetist,
Massachusetts
General Hospital

intubation

orally with an Olym$us LF-I

intubation

in Siberoptic

within IO intubations

than 90% success on the first

I-II

expertise

offiberopic

(as defined

by the learning

safety is maintained.

objectives) bp the tenth intubation,

and
Directors of anesthesia residency training shou,ld con-

these date. in determining

training

protocols

for

teaching

fiberoptic

Laryn-

goscopy and intubation

~~w~~~~~ Fiberoptic laryngoscopy;

anesthesia; residency training.

J. Clin. Anesth., 1989, val. 1, no. 3

intubation;

clinicat competence;

Instruction in fiberoptic

Fiberoptic
lary~gosco~yli~tubation
is an accepted
technique for management of the difficult airway.,
We were concerned about how to teach the skill of
using the fiberoptic laryngoscope to new residents.
The learning objectives for the residents were to
achieve a time for intubation of 2 minutes or less and
greater than 90% success on the first attempt at intubation. Ovassapian et al3 demonstrated that a stepwise training program
is a more effective method for
learning than traditional teaching (i.e., learning on the
difficult airway patient), that is, the time to learn is
not on the patient with a difficult airway, but rather
in a safe and controlled environment involving a patient with normal laryngeal anatomy. We chose to test
the hypothesis that an acceptable level of technical
expertise (as defined by the learning objectives) in
fiberoptic iaryngoscopy
an
intubation can be acquired within 10 intubations. This approach is also
intended to be used to maintain the skill once it is
learned because it can be incorporated
into routine
anesthetic
approaches
requiring
intubation.
This
method does not require any special oral-pharyngeal
preparation or sedation, and, thus, should not delay
the start of surgery or cause patient discomfort.

Ninety-one ASA physical status I-II patients (60 men

and 31 women), with normal laryngeal anatomy, between the ages
f 23 and 65 years, scheduled for
extracorporeal
s ckwave lithotripsy, were intubated
eroptic scope. The study was apuman Studies Committee, and ins obtained from each patient. Four
randomly selected residents participated in the study.
Each resident was under the supervision of the same
staff anesthesiologist. The residents performed all of
their fiberoptic intubations within a l-month period.
All of the residents had completed at least 8 months
of anesthesia residency training and had no prior exrforming fiberoptic laryngoscopy and inecause one resident intubated only I5
ly the results of intubations 1 to 15 for
each resident are included in the study; thus, n = 60
for the total number of patients intubated in the study.
The monitoring equipment used included an aure cuff (Dinamap Critikon 845
set at l-minute cy
s 5 I I, Sllsboro,
0
ration monitor
ellcor N- 100 Oximeter, Hayward,
CA), end-tidal
monitor (Puritain-Bennett
Datex,

laqng-oscopy and endotracheai

intubation: Johmon

and Roberts

recording paper, W7il ingcon: &IA), and

a teaching adapter for the fiberoptic laryngoscope.
The riberscope used (Olympus IF- 1i Tokyo, Japan)
is 60 cm long with a 4.0-mm diameter tip. This scope
was chosen because the extra length allows for more
free scope once an endotracheal tube is placed, which
facilitates manipulation and endstracheal intubation.l
Also, the scope is stiffer, an important quality in view
of the reports that with more flexible fiberoptic scopes,
kinking of the scope with advancement of the endotracheal tube may occur, thus p
intubation.~~6 A bite block (Olym
was used. Each
resident had only one l%minu
iiberoptic scope under supervision on a teaching manikin before participating in the study. Each patient
was premeditated
with midazolam l-2.5 mg IV and
fentanyl 1 pglkg IV just prior to induction. Each patient was then asked to breathe IOO% 0, for 3 minutes
and hyperventilate
to an end-tid
22-32 mmHg. Induction of anest
with the administration of sodium
kg IV followed by succinylcholine I mg/kg IV to provide muscle relaxation. Patients were then ventilated
by mask with 2-4% enflurane or isoflurane and 100%
0, for 60-90
seconds or with 100% 0, for 60-90
seconds, at which point fiberoptic laryngoscopy and
intubation were performed with the resident standing
directly behind the patients head. Also at that time,
the supervising staff performed
aw lift to bring the
tongue away from the posterior
larynx. If the resident did not intubate the patient within 3 minutes,
sodium pentothal l-2 mg IV was administered, mask
ventilation with 100% 0, for 3-5 breaths was performed, and fiberoptic intubation was repeated. The
time for intubation was measured from the last breath
by mask to the first breath vin the endotracheal tube
minus, the time during which repeat mask ventilation
was performed.
Prior to, during, and postlaryngoscopy and intubation,
0, saturation
mean arterial
pressure (MAP), ETCO?, and heart rate (HR) were
recorded continuously. The oral route ~2s chosen for
laryngoscopy and intubation because it tends to be
more technically difficult to perform than the nasal
route. Hopefully, gaining proficiency
of the oral
method facilitates learning the easier nasal route.

The Yearning curves were generated using logarithmic analysis of the data. Data are reported
as mean
2 SD. Individually, the learning curves were established by plotting the time for i~t~~bat~ol~against the
intubation number, with the maximum intubation
J. Clin. Anesth., 9989, vd. 1, no. 5

345

Orig-inal

Contributiow

number being 35. As a group, the learning curve was

established by calculating the mean time for intuhation for residents 1 to 4 at each intubation number
(n = f-15). The mean time was then piotted against
each intubation number (n = l-15) to generate the
group learning curve.

Ninety-one intubations were performed by the four

resident anesthesiologists with a mean time of 1.92 t
I .45 minutes per intubation. The mean time for intubation for the individual residents 1, 2, 3, and 4
were 2.1 i 1.35 minutes (n = 15), 1.91 2 1.38 minutes (n = 26), 1.69 2 1.14 minutes (n = 31), and
2.13 It 2.08 minutes (n = 18), respectively.
The mean time for intubation for the residents on
the first 5 patients was 3.25 i- 1.97 minutes, for patients six to ten was 2.59 + 1.59 minutes, and for
patients 11 to 15 was 1.34 I 0.31 minutes.
Successful fiberoptic intubation for each resident
was obtained on the first attempt 50% of the time on
the first 5 patients, 90% of the time on patients 6 to
10, and 100% of the time on patients 1 B to 15. Successful intubation after the 15th patient was obtained
on the first attempt 93.5% of the time.
A learning curve was established for the residents
as a group and individually (Figures 1 to 5). There is
a rapid decline in the mean t SD intubation time
from 4.00 i 2.91 to 1.53 + 0.76 minutes by the 10th

I ntubation

Figure 2. Individual learning curve for resident 2.

intubation. From the 10th to the 15th intubation, the

mean intubation time leveled off between 1.2 to 1.58
minutes (Tnble I; Figure 5).
There was a decrease in 0, saturation in seven
patients, yet it was never lower than 95%.
failed to receive preoxygenation.
Four pa&mts
were
greater than 20% above ideal body weight, received

Num be

Figure

1. Individual learning curve for resident

346

J. Clin. Anesth.,

1989, vol. 1, no. 5

Figure 3. Individual learning curve for resilient 5.

Indruction

in fiberoptic lqngoscop~

alzd endotyacheal inttubation. .ohnson and Roberts

Mean Time for Intubation:

4.00
4.45
3.30
2.42
1.92
1.92
2.55
1.78
2.31
1.53
1.58
1.20
1.33
1.40
I.30

1
3
4
5
6
7
8
9
10
11
12
13
14
15
*Resident

Residents

1 required

6.05 minutes

tc

iniubare

t
P
i
iIT
+
i
i
ir
z
t
+_

i to 4

2.9I
2.11
1.88
1.34
0.42
0.98
0.98
0.75
2.53*
0.76
0,36
0.11
0.07
0.46
0.40

her ninth

patient.

Figure 4. Individual learning curve for resident 4.

preoxygenation,

and

had

starting

0,

saturations

of

lOO%, yet still had mild &saturation

during

non. The

for these four

mean time for intubation

intuba-

was 1.46 t 0.46 minutes. Two patients had

intubation times of 7.0 and 8.5 minutes,-and had 0,
saturation d
se from 100% to 9
MAP and
were recorded i-mm
and immediately
after the endotracheal
tube was
placed for all 9! intubations. Th
tubation were 89.4 t 14.5 m
beats/minute, respectively. The
mediately after intubation was 107.5 + 21.16 mmHg
and 95 + 14.09 beats/minute. The MAP increased
16.86% and the MR increased 15.42%.
patients

The goal of this study was to test the hypothesis that

an acceptable level of technical expertise in fiberoptic
laryngoscopy and intubation can be acquired within
10 mtubations. The resident learning curve for ah the
residents (Figure 5) suggests that fiberoptic laryngoscopy and intubation is learned within IO intubations
and that the time to intubation remains flat after that
time. The individual resident learning curves (FZ~z~es
I to 4) are almost identical to the group learning curve
(Figure 5j, suggesting that all of tbe residents learned
at about the same rate. If inrubation number 9 is
exciuded, the standard deviation for the -mean mtubation
Figure 5. Group learning curve for residents 1 to 4. This
curve was estabkhed by calculating the mean time for intubation from the sum of the individual resident times for
intubation and plotting this number against the incubation
number.

times

for the group

learning

Curve (Table

1)

decreases with increasing krtubation number, suggesting that the resident rates of learning were equal.
Resident i reqluired 6.05 minutes to intubate the ninth
patient (Figure 1) secondary to an unanticipated difficult airway.
j. Clin.

Anesth.,

1989, WY. 1, no. 5

345

Ckiginal Contributions

The results suggest tbat 10 fiberoptic intubations

within a l-month period enables residents to meet to
learning objectives in the use of the fiberoptic laryngoscope. 0ur results are supported by the results
of a study done by Delaney and Hessler,7 who demonstrated that the time for flexible fiberoptic nasotracheal intubation, decreased significantly by the 9th
to 10th intubations. After acquiring competence on
normal airway anatomy, one is better prepared TV
manage more difficult airways. Minimal standards for
cognitive and technical skills (to be considered cornpetent) to perform certain procedures are being established in internal medicine. The American College
of Physicians has set minimum criteria necessary to
obtain clinical competence in the use of flexible sigmoidoscopy, esophagogastroduodenoscopy,
and colonoscopy .8-11 Because the fiberoptic larvngoscope is,
in our opinion, the definitive instrument for evaluation of the airway, every anesthesiologist
should acquire clinical competence in its use. A recent study
conducted by Spielman et ~1.~ asked 110 private practice anesthesiologists,
76 chairpersons of anesthesiology, and 138 members of the Society for Education
in Anesthesia which procedural skills a resident must
be competent in to be a consultant in anesthesiology.
The procedure that received the highest endorsement
from these three groups was fiberoptic laryngoscopy
and intubation. It is our responsibility as experts in
airway management
to establish learning objectives
for obtaining and maintaining clinical competence in
fiberoptic laryngoscopy and intubation.
The authors realize that the technique of fiberoptic
intubation is most often used during awake nasotracheal intubation; however, by learning under the more
difficult condition (anesthetized and oral intubation),
we believe this approach facilitates fiberoptic intubation by other methods. In awake nasotracheai
intubation, appropriate sedation and nasal and oropharyngeal preparation
must be performed. l3 Our
study was not designed to teach this technique because
all patients were under general anesthesia.
Helpful techniques to facilitate successful oral or
nasal fiberoptic intubation are as follows: (1) have an
assistant perform a jaw thrust; (2) keep the fiberscope
in the midline of the pharynx during advancement;
(3) if the endotracheal tube meets resistance and fails
to enter the trachea, rotation of the tube 90 counterclockwise usually solves the problem because the
endotracheal tube may be getting caught on the epiglottis and/or vocal cords.
Several questions are raised by our study. First, can
meeting the learning objectives (as defined in the study)
be equated to obtaining clinical competence in fiberoptic intubation? Our results suggest that meeting the
348

J. Clin. Anesth.,

1989, vol. 1, no. 5

learning objectives enables one to be competent in the

mechanicai
manipulation
of the fiberoptic
sco
identifying normal pharyngealilaryngeal anatomy, and
proper placement of the endotracheal tube in the trachea. Meeting the learning objectives does ensure obtaining competence
in awake nasal or awake oral
fiberoptic intubation. However, we did not test the
residents at a time subsequent to this training period.
Our sample size of residents and the number of patients was small, and only one staff person and one
type of fiberoptic scope were used. The skills of the
residents may vary, and it is conceivable that some
residents may have a shorter or longer learning curve.
Despite these potential limitations of our study, the
consistency of the results and the similarity- of findings
of those of others7 provide support for the concept
that our conclusions are justified. Second, bow many
ns does one need to persuccessful fiberoptic int
idere
form under supervision
at one
technically competent?
can meet the learning o ectives (indicating technical
competence) by the 10th fiberoptic intubation within
a l-month period. Third, are the results using one
specific fiberoptic laryngoscope (Olympus LF- I ) applicable when using another type of fiberoptic laryngoscope? We do not know. The Olympus LF-I was
selected for the study because it possesses features
(discussed previously) that are believed to facilitate
successful fiberoptic intubation, which were absent on
other fiberscopes at the time of the study. The authors
tried to construct an objective study of an educational
process that is usually approached in a highly subjective manner. Additional studies need to be done addressing the issues and questions raised in this study.
Directors of anesthesia residency training should consider these data in establishing protocols for teaching
fiberoptic laryngoscopy and intubation.

The authors would like to thank the residents who participated in the study: Drs. Eori Bannon, Donald Schwartz,
Robert Laflam, and Calvin Johnson.

1. Sia RL, Edens ET: Flexible fiberoptic endoscopy in difficult intubation. Ann Otolaygol 1981;90:308-9.
2. Messeter KH, Pettersson RI: Endotracheai intubation
with the fibreoptic bronchoscope.
Anaesthhpsia 1988;
353294-8.
3. Ovassapian A, Dykes M, Gohnon M: A. training pro-

Instruction

4.
5.
6.

7.

8.

in fiberoptic

gramme for fiberoptic nasotracheal intubation. Use of

model and live patients. Anaesthesia 1983;38:795-8.
Moorthy SS, Dierdorf S: An unusual difficulty in fiberoptic intubation. Anesthesiology 1985;63:229.
Green C: Improved technique for fiberoptic intubation.
Anesthesiolo,g 1985;64:835.
Ovassapian A: Failure to withdraw flexible fiberoptic
laryngoscope after nasotracheal intubation. Anesthesiol0,g-J 1985;63: 124-5.
essler R: Emergency flexible nasotraDelaney MA,
cheal intubation: A report of 60 cases. Ann Emerg Med
B988;!7:919-26.
Wigton RS: Cli:nical competence in the use of flexible
sigmoidoscopy for screening purposes. Ann Intern Med
1987;107:589-91.

larpgoscopy

and endotracheal

intubation: Johnson. and Roberts

9. Kahn Kk, Wigton RS: Clinical competence in diagnostic

e~;o~bagogastrod~odenoscopy.
Ann Intern Med 1987;
107:937-9.
10. Anchord JL, Wigton RS: Clinical competence in colonoscopy. An?2 Intern Mesl 19&7;107:772-4.
11. Federated Council for Internal Medicine: Enhancing
standards of excellence in internal medicine training.
Ann intern Med 1987;107:775-8.
12. Spielman FJ, Levin KJ, Fatherly JA, Waterson CK:
Which procedural skills should be Iearned by anesthesiology residents. Amesthesiologg [Sup
13. Ovassapian A: The role of fiber-optic endoscopy in
airway management. Semin A9zesth 1987;6:93-104.

,J. Clin. Anesth.,

1989, vol.

!,

no.

34