RUSH University: Respiratory Care

RC 563 Introduction to Research

RUSH UNIVERSITY – Respiratory Care

The difference between using High fidelity simulation and low fidelity simulation with airway management

Airway management is essential in the respiratory care practice. The knowledge and skill needed in this matter include bag and mask ventilation (BMV), laryngeal mask airway (LMA), and endotracheal tube insertion (ET). The process of providing the respiratory practitioner with the confidences of performing this task are widely differed due to the way this necessary skill and knowledge produced to the end-users. In this study, we will measure the different between two groups of participants on the skill and knowledge using BMV, LMA, and ET based on their confidence

pre and post airway management introduction. There will be a two method of airway management introduction, one with low-fidelity simulation and other with high-fidelity simulation.
The use of high-fidelity simulation is increasing as the science and technology advances. In the medical profession, the use of this new technology can enhances the knowledge and skill needed by the medical practitioner. The high expenses of this technology needed to justify it usage on order to continue applying it to the medical field. In this study, we will evaluate the amount of enhancements the respiratory care practitioners to use high-fidelity simulation VS low-fidelity simulation.

Airway Description and function:
The path that air follows to get into and out of the lungs. The nose and mouth is the only passages that air pass though going to the lungs. Pharynx is where the air coming from mouth and nose accumulate and passes though it to the larynx. The airflow then goes through the vocal cord to the lung. The airway consists from the upper and the lower airways. The upper airways are the mouth, nose, and pharynx where the located above the vocal cords. The lower airways, which are located below the vocal cords, are trachea, bronchus, and bronchioles. Airways main functions are to allow the air to flow back and forth from the lung. Airways also do responsible for the function of filtering the air from the irritant’s and contagious particles. The air inters the body through that airway as a dry non-humidified air therefore the airways make the humidification needed to keep the lungs from drying.

The need for the artificial airways:
The need for the artificial airway comes whenever there is a need for ventilation assistance or the patient unable to securely protect his airways. On other cases if the patients unable to efficiently clear his lung from the secretion or a frequent aspiration happened to him then the artificial airway needed. The artificial airway used frequently during the operation if the patient going to be sedated to protect his airways during the procedures.

Types of airways managements
Laryngeal Mask Airway (LMA):
The Laryngeal Mask Airway (LMA) is apparently the most popular. This kind of artificial tube has more than one type; one of it is a common used called classic CLMA. The two other types of LMA are the intubating LMA (ILMA), and it can be used during mechanical ventilation and ProSealt LMA (PLMA). Although first planned for voluntary anesthesia, it has rapidly increased in progress in emergency care. The percentages about success on utilizing this kind of the airway management tube are from 64 to 100 % according to one study. The use of this device between non-experienced health care practitioners such as nurses, respiratory therapist, and emergency medical services providers are becoming more popular, and they tend to fever it over the other artificial airways. Training in how to use CLMA is easier to apply than the skill needed for the endotracheal intubation (ET-tube). When comparing this to the Bag and Mask Ventilation (BMV) this way of ventilation give more secure and dependable way of ventilating patients in the cardiac arrest and it is recommended by the resuscitation guidelines to be used during cardiac arrest and emergencies airway management.
The main use for the LMA was in the emergencies that because it is easier than endotracheal tube intubation and does not require a laryngoscope. At the cardiac Intensive Care Unit (ICU) the most frequently artificial airway device applied is the classic CLMA because, it is easy to apply and does not need a lot of experience from the practitioner. The other type of LMA is available also at the Cardiac ICU, which is the Intubating LMA (ILMA), and the ProSealt LMA (PLMA). LMA does have a high success rate in the airway managements and might be used for blind intubation in the future even though there are not enough studies supporting this thesis.

Bag and Mask Ventilation (BMV):
This technique is the simplest one for the airway management. It composed of two equipment, one is the mask and the second one is the bag. The mask involve in most of the studies is a clear made of plastic and transparent to make it easily view what is happening under the mask. The mask could be round or take the other shape but it should be cover the nose and mouth when it used easily. The edge of the mask should be cushioned to make it seal without the need for more pressure. The bag usually from 1200 to 1600 ml in size and has a relieve valve with an oxygen connection. Bag and mask ventilation need a skills to properly apply it and seal it while giving the right amount of squeeze. The head need to be positioned in the right position to make sure the tongue is not obstructing the airway. During the bag and mask ventilation the depth of the breath and the length of the breath will affect the amount of air delivered to the patient. The practitioner while delivering the bag and mask ventilation need to be at the bead of the bed and to use both of his hands, One to squeeze the bag and the other hand to secure the mask over the mouth and nose. The effectiveness of the bag and mask ventilation should be measured from the amount of the chest rise and from the patient’s vital signs response.

Endotracheal Tube (ET-Tube):
This is the most invasive and complicated airway management technique. This procedure need more skilled practitioners and need more measure of assessment after it inserted. The endotracheal tube is a plastic tube made of clear plastic and come by multiple sizes and types. The is infants, pediatrics and, adult endotracheal tubes differentiated by the tube size. Endotracheal tube can be either a single lumen or double lumen. The need for the tube will rise as the patients’ ability to ventilator independently decreases. During the endotracheal tube incretion there must use a laryngoscope to view the glottis to guide the tube through it. The technique of placing the endotracheal tube requires the proper use of the laryngoscope. Misusing the laryngoscope can traumatize the patient’s mouth and make it harder to place the tube properly.
Misplacement of the endotracheal tube is a very dangerous and can lead to death for this reason the placement of the tube should be followed by CO2 detector and to auscultate the patient chest for proper placement.

High fidelity simulation

Types and Methods and, outcomes
When medical students introduced to the septic and cardiogenic shock.

They used a high human like simulator, which can provides the signs and symptoms of the shock. It can show the cardiac shock or the septic shock according to the scenarios they entered in the system earlier. The medical students during the study will be introduced to the shock signs and symptoms through the high fidelity simulator. The simulator will show the natural response to the student action to treat what they diagnose. If they select the wrong action of treatment the simulator signs and symptoms will be deteriorates accordingly. The high fidelity simulator gives back the reflection to the intervention immediately after the students apply

it.1
SimMan was used for the high fidelity medical simulation in the international life support course. SimMan is a high fidelity manikin based simulator. Course participants, including doctors, nurses, and pre-hospital personnel, were given pre- and post-course questionnaires quantifying their confidence in knowledge and treatment of trauma resuscitation, as well as their postures towards the utility and realism of immersive simulation. The participants were randomly selected to take a course examination either before or after their simulator session.2 To compare the efficacy of high-fidelity medical simulation, Littlewood KE 1 Did a study utilizing 85 third-year medicos and found that students demonstrated more preponderant understanding of shock following simulation than after CBD. Kim TE 2 did a randomized, prospective survey regarding postures toward High Fidelity Medical Simulation (HFMS) and found high-fidelity medical professionals of different backgrounds and experience-accepted simulation. Postures towards simulation and aplomb amended after simulator sessions, as did test scores.1, 2
There has been concern in the utilization of high-fidelity medical simulation to estimate production. We hypothesized that professional and nonprofessional performance in a simulated environment was cognate to other sundry criterion measures, providing evidence to fortify the validity of the scores from the performance-predicated assessment. The associations between simulator performances, both for professional and nonprofessional skills, and other markers of ability provide some evidence to fortify the validity of simulation-predicated assessment scores. Replication studies with more sizable covering numbers of residents are warranted.3
Mudumbai SC4 used high-fidelity medical simulation to investigate failure modes of technology and equipment and human-machine interactions.
Nine pairs became vigilant of the low fraction of inspired O2 Fio2 alarm. Only three pairs apperceived the high fraction of inspired N2O. One group failed to agonize both the low Fio2 and the high alarms. Nine groups took 3 or more steps afore instigating a definitive route of oxygenation. Seven groups utilized the auxiliary O2 flow meter at some point during the management steps.
In this descriptive study, they suggests that the utilization of high-fidelity simulations may be a promising path, further to examine hypotheses cognate to failure modes of equipment and possible management replication strategies of clinicians.4
135 hospital employees engaged in nine SimCode resuscitations between 2006 and 2008. response production data were obtained through in situ SCA simulations on hospital medical floors. SimCode data set was connected with chart review-based dataset of original (live) in-hospital resuscitation system review for SCA cases of comparable acuity and complexity. High-fidelity medical simulation of unexpected cardiac arrest (SCA) gives a chance for systematic probing of in-hospital resuscitation systems. Researchers produced and executed the SimCode program to assess simulation's capacity to produce significant data for operation security review and manage concordance of found outcomes with institutional quality data. On-site simulations, fortunately, created SCA response measures for association with real resuscitation chart analysis data. Continued study may improve simulation's performance in quality leaderships, explain methodological errors and increase SCA response.5
Of the second-year residency, 16 of them enroll in a study performed at Rhode Hospital Medical Simulation Center. To measure the effective of teaching pediatric residents airway skills and teamwork a high-fidelity medical simulation used. Simulation is employed to teach technique, abilities and, cooperation. There is restricted information on the effectiveness of this educational approach. We assume that the simulation is useful for training pediatric residents airway experiences and teamwork. This study confirms simulation-enhanced educational strategies for improving performance and teamwork skills. This method is useful in education pediatric residents airway skills and teamwork foundation essential to efficiently handle an acute airway situation.6
A prospective observational study performed on postgraduate second- and third years radiologists residents. After regular academic education on departmental contrast reaction rules, residents engaged exclusively in high-fidelity medical simulations of intense contrast reactions. Residents' achievement of planned critical activities was noted. Dissimulation and post-simulation multiple-choice examination assessed residents' understanding of departmental rules. Each resident performs 5-point, Likert-type surveys assessing comfort level whilst controlling contrast reactions and perceptions of the simulation event. A medical simulation as an assessment implement utilized for the measurement of radiology residents' adherent with the procedure rules of the contrasting response and to calculate their thoughts of the simulation event. After standard didactic applies of the departmental contrast reaction protocols, residents opposed individually in high-fidelity medical simulations of severe contrast reactions. All residents vigorously acceded that the simulation was a valuable inculcate experience while 85% vigorously acceded that it amended their skills in managing acute contrast reactions. 7
High-fidelity simulation for a chest surface burns escharotomy design for visible authenticity and as an instructional medium. A simple step-sagacious technique for preparing a chest wall burn moulage that may be provided to mannequins of different sizes and shapes is defined. The goal of the moulage was to enhance the realism of the scenario, but supplemental to provide a chest wall escharotomy to be presented. In the event of the chest wall injury model, moulage was utilized as more than a visual realism enhancing strategy. It accommodated as edifying implements in its right, sanctioning demonstration of a method infrequently carried outside the surfaces of major burns centers. The use of the high fidelity simulation work better to create near to real effect and give the high of outcome.8
High-fidelity medical simulators such that they have frequently grown more life-like.

To create a more life-like reality, it is necessary to consolidate into the simulation conditions as many characteristics found in the real life environment as feasible. One of these pieces is the transfer of diagnostic data In this descriptive study a highly cost-effective information center which gives the real-time performance of lab values, electrocardiograms, and radiologic studies in a way that is utmost alike to which exists in every Emergency Departments. This information center provides for a further practical copied patient conflict. It helps members smooth experiences included in radiographic analysis utilizing an interface located in the hospital. It also promotes continuous course of events by streamlining the performance of laboratory and electrocardiographic information. Employing this information service has enabled us to improve the effectiveness of our synopses, enhance member fulfillment, and give some extra work at interpreting information as it would be seen in the hospital.9

To assess if high-fidelity medical simulation can be used as an evaluation means for pediatric residents' ability to control an acute airway, a prospective observational study performed with a sample of 16 pediatric residents. The information clarifies many fields of interest with resident experiences in maintaining an airway. This outline implies that high-fidelity medical

simulation can help a resident's experience to maintain an airway as well as a program's effectiveness in preparing the abilities required to achieve an intense pediatric airway.

Low fidelity simulation types

Types, Methods and, Outcomes:
The medical students used for the low fidelity simulation a case based discussion (CBD). A case of cardiogenic shock and a septic shock was discussed in details. The medical students have to read and discuses the cases one by one and decide what is the proper treatment needed for every case.
Review rates were higher in all measurements for the nature of the shock experienced by simulation. This was correct regardless of the shock type. Scores compared with patient evaluation and invasive monitoring, however, showed no distinguishing between groups or in crossover comparison.1

Participants of varying backgrounds and degrees of clinical experience were surveyed and tested including comfort level with simulation as a training method, perception of the realism of HFMS, and reported self-confidence in knowledge, experience and training in trauma care. Test scores were improved in the post-simulation group as opposed to the pre-simulation group. In this subject, students showed greater understanding of shock pursuing simulation than after CBD.2
A group of 6 short 5-minute scenarios and 1 longer 30-minute scenario. The short scenarios quantified technical skills, whereas the longer one fixated on nontechnical skills. Two independent raters scored subjects utilizing analytic and holistic classes. Short situations included acute hemorrhage, endotracheal tube blockage, bronchospasm, hyperkalemia, pneumothorax caused by ventilator, and unstable ventricular tachycardia. The long situation concerned management of myocardial ischemia/infarction leading to cardiac apprehends. Scores from the simulations were correlated. There were moderate correlations between sundry participant scores from the simulation-predicated assessment and aggregate rankings predicated on the global ranking means and residency examination scores.3
The value of an equipment failure simulation situation, oxygen /nitrous oxide N2O pipeline crossover, to examine residents' learning and their use of anesthetic apparatus in a rapidly increasing crisis is not worthy unless it done through a high fidelity simulation. This type of process will not be properly be performed with a low fidelity simulation or regular case scenarios.4
When looking to the low fidelity simulation with the radiologist residents it was not provide any positive indication supporting it. Standard didactic instruction may provide insufficient training and reinforcement of acute contrast reaction management skills. Medical simulation may present an important means of evaluating residents' abilities and satisfaction levels in controlling severe contrast reactions. This issues support strongly the superiority of the high fidelity simulation over the low fidelity one.7

Issues:
The different between the two types of modalities and the limited data of the some studies make it hard to do direct comparisons between it.1
If the sample of the study small then the outcome would not be generalized further more therefore, testing is required to validate the findings of the small studies 2
Possible reasons of differences among resuscitation response datasets are the combined individual volume and information barriers, simulation fidelity, different SCA scenario supplies and unique purpose of SCA response performance by corresponding evaluating methodologies.5

References
1. Littlewood KE, Shilling AM, Stemland CJ, Wright EB, Kirk MA. High-fidelity simulation is superior to case-based discussion in teaching the management of shock. Med Teach 2013;35(3):e1003-e1010.

2. Kim TE, Reibling ET, Denmark KT. Student perception of high fidelity medical simulation for an international trauma life support course. Prehosp Disaster Med 2012;27(1):27-30.
3. Mudumbai SC, Gaba DM, Boulet JR, Howard SK, Davies MF. External validation of simulation-based assessments with other performance measures of third-year anesthesiology residents. Simulation in Healthcare 2012;7(2):73-80.

4. Mudumbai SC, Fanning R, Howard SK, Davies MF, Gaba DM. Use of medical simulation to explore equipment failures and human-machine interactions in anesthesia machine pipeline supply crossover. Anesth Analg 2010;110(5):1292-1296.

5. Kobayashi L, Lindquist DG, Jenouri IM, Dushay KM, Haze D, Sutton EM, et al. Comparison of sudden cardiac arrest resuscitation performance data obtained from in-hospital incident chart review and in situ high-fidelity medical simulation. Resuscitation 2010;81(4):463-471.

6. Sudikoff SN, Overly FL, Shapiro MJ. High-fidelity medical simulation as a technique to improve pediatric residents' emergency airway management and teamwork: A pilot study. Pediatr Emerg Care 2009;25(10):651-656.

7. Tubbs RJ, Murphy B, Mainiero MB, Shapiro M, Kobayashi L, Lindquist D, et al. High-Fidelity Medical Simulation as an Assessment Tool for Radiology Residents' Acute Contrast Reaction Management Skills. Journal of the American College of Radiology 2009;6(8):582-587.

8. Foot C, Host D, Campher D, Tomczak L, Ziegenfuss M, Cohen J, et al. Moulage in high-fidelity simulation-a chest wall burn escharotomy model for visual realism and as an educational tool. Simulation in Healthcare 2008;3(3):183-187.

9. Taylor T. How to create a clinical data station for use in a high fidelity medical simulation lab. Simulation in Healthcare 2008;3(2):128-130.

10. Overly FL, Sudikoff SN, Shapiro MJ. High-fidelity medical simulation as an assessment tool for pediatric residents' airway management skills. Pediatr Emerg Care 2007;23(1):11-15.