Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial

doi:10.1111/anae.16491

Randomized Controlled Trial

. 2025 Apr;80(4):395-403.

doi: 10.1111/anae.16491. Epub 2024 Nov 27.

Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial

Sascha Ott^{1

2}, Lukas M Müller-Wirtz^{3

4}, Sergio Bustamante⁵, Julian Rössler^{6

7}, Nikolaos J Skubas⁵, Karan Shah^{6

8}, Daniel I Sessler^{6

9}, Alparslan Turan^{6

9}, Kurt Ruetzler^{6

10}; VLS trial group

Affiliations

¹ Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany.
² Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.
³ Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany.
⁴ Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany.
⁵ Division of Cardiothoracic Anesthesiology, Department of Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁶ Outcomes Research Consortium, Houston, TX, USA.
⁷ Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
⁸ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
⁹ Center for Outcomes Research and Department of Anesthesiology, UTHealth, Houston, TX, USA.
¹⁰ Division of Multispecialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.

PMID: 39604038
DOI: 10.1111/anae.16491

Randomized Controlled Trial

Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial

Sascha Ott et al. Anaesthesia. 2025 Apr.

. 2025 Apr;80(4):395-403.

doi: 10.1111/anae.16491. Epub 2024 Nov 27.

Authors

Affiliations

¹ Department of Cardiac Anaesthesiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany.
² Charité - Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany.
³ Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Saarland, Germany.
⁴ Department of Anesthesiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany.
⁵ Division of Cardiothoracic Anesthesiology, Department of Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
⁶ Outcomes Research Consortium, Houston, TX, USA.
⁷ Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland.
⁸ Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA.
⁹ Center for Outcomes Research and Department of Anesthesiology, UTHealth, Houston, TX, USA.
¹⁰ Division of Multispecialty Anesthesiology, Department of Anesthesiology, Cleveland Clinic, Cleveland, OH, USA.

PMID: 39604038
DOI: 10.1111/anae.16491

Abstract

Introduction: The number of tracheal intubation attempts required to reach proficiency in videolaryngoscopy with hyperangulated blades is unknown. Understanding this training requirement might guide training for clinicians who perform laryngoscopy. We therefore performed a planned sub-analysis of a randomised controlled trial comparing tracheal intubation success with videolaryngoscopy vs. direct laryngoscopy to determine the number of tracheal intubations with a hyperangulated videolaryngoscope blade needed to provide an acceptable first-attempt success rate.

Methods: We included clinicians from a randomised controlled trial who were familiar with direct laryngoscopy and Macintosh-blade videolaryngoscopy but inexperienced with hyperangulated videolaryngoscopy. Cumulative sum statistics were used to generate learning curves with acceptable success rates of 85% and unacceptable success rates of 70% for the primary outcome of first-attempt tracheal intubation success.

Results: We included 223 clinicians (25 consultants; 35 certified registered nurse anaesthetists; 36 student registered nurse anaesthetists; 46 fellows; and 81 residents) who attempted tracheal intubation in 4312 procedures. The median (IQR [range]) number of tracheal intubations per clinician was 15 (8-25 [1-77]). First-attempt failure was low, with only 72 failed first attempts overall, and was comparable across clinician groups. In total, 133 (60%) clinicians crossed the acceptable success rate boundary while the remaining 90 (40%) clinicians crossed neither the acceptable nor unacceptable success rate boundaries. Among clinicians who crossed the acceptance boundary, the median (IQR [range]) number of attempts for learning was 12 (12-12 [12-26]).

Discussion: Clinicians experienced in tracheal intubation with direct laryngoscopy but unfamiliar with hyperangulated-blade videolaryngoscopy can achieve proficiency after approximately 12 attempts.

Keywords: anaesthesia; laryngoscopy; learning curve; medical education; videolaryngoscopy.

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References

1. Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation: learning and performance. Anesthesiology 2003; 98: 23–27. https://doi.org/10.1097/00000542‐200301000‐00007.
1. Piegeler T, Neth P, Schlaepfer M, et al. Advanced airway management in an anaesthesiologist‐staffed helicopter emergency medical service (HEMS): a retrospective analysis of 1047 out‐of‐hospital intubations. Resuscitation 2016; 105: 66–69. https://doi.org/10.1016/j.resuscitation.2016.04.020.
1. Thoeni N, Piegeler T, Brueesch M, et al. Incidence of difficult airway situations during prehospital airway management by emergency physicians – a retrospective analysis of 692 consecutive patients. Resuscitation 2015; 90: 42–45. https://doi.org/10.1016/j.resuscitation.2015.02.010.
1. Kohl V, Wunsch VA, Muller MC, et al. Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial. Anaesthesia 2024; 79: 957–966. https://doi.org/10.1111/anae.16326.
1. Kriege M, Lang P, Lang C, et al. A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial. Anaesthesia 2024; 79: 801–809. https://doi.org/10.1111/anae.16250.

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[1] Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation: learning and performance. Anesthesiology 2003; 98: 23–27. https://doi.org/10.1097/00000542‐200301000‐00007.

[2] Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation: learning and performance. Anesthesiology 2003; 98: 23–27. https://doi.org/10.1097/00000542‐200301000‐00007.

[3] Piegeler T, Neth P, Schlaepfer M, et al. Advanced airway management in an anaesthesiologist‐staffed helicopter emergency medical service (HEMS): a retrospective analysis of 1047 out‐of‐hospital intubations. Resuscitation 2016; 105: 66–69. https://doi.org/10.1016/j.resuscitation.2016.04.020.

[4] Piegeler T, Neth P, Schlaepfer M, et al. Advanced airway management in an anaesthesiologist‐staffed helicopter emergency medical service (HEMS): a retrospective analysis of 1047 out‐of‐hospital intubations. Resuscitation 2016; 105: 66–69. https://doi.org/10.1016/j.resuscitation.2016.04.020.

[5] Thoeni N, Piegeler T, Brueesch M, et al. Incidence of difficult airway situations during prehospital airway management by emergency physicians – a retrospective analysis of 692 consecutive patients. Resuscitation 2015; 90: 42–45. https://doi.org/10.1016/j.resuscitation.2015.02.010.

[6] Thoeni N, Piegeler T, Brueesch M, et al. Incidence of difficult airway situations during prehospital airway management by emergency physicians – a retrospective analysis of 692 consecutive patients. Resuscitation 2015; 90: 42–45. https://doi.org/10.1016/j.resuscitation.2015.02.010.

[7] Kohl V, Wunsch VA, Muller MC, et al. Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial. Anaesthesia 2024; 79: 957–966. https://doi.org/10.1111/anae.16326.

[8] Kohl V, Wunsch VA, Muller MC, et al. Hyperangulated vs. Macintosh videolaryngoscopy in adults with anticipated difficult airway management: a randomised controlled trial. Anaesthesia 2024; 79: 957–966. https://doi.org/10.1111/anae.16326.

[9] Kriege M, Lang P, Lang C, et al. A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial. Anaesthesia 2024; 79: 801–809. https://doi.org/10.1111/anae.16250.

[10] Kriege M, Lang P, Lang C, et al. A comparison of the McGrath videolaryngoscope with direct laryngoscopy for rapid sequence intubation in the operating theatre: a multicentre randomised controlled trial. Anaesthesia 2024; 79: 801–809. https://doi.org/10.1111/anae.16250.

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Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial

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Learning tracheal intubation with a hyperangulated videolaryngoscopy blade: sub-analysis of a randomised controlled trial

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