B38-03 Beyond Numbers: Structural and Educational Barriers to Airway Competency in Pulmonary and Critical Care

Abstract Rationale The ACGME mandates competence in endotracheal intubation for pulmonary critical care medicine (PCCM) fellows. Traditionally, procedural numbers have served as surrogates for expertise; however, case volume fails to capture confidence or competence. Moreover, airway experience can be limited at academic medical centers (AMC) when procedures are shared among trainee groups and constrained by institutional policies. This study evaluated a PCCM airway curriculum at an AMC where anesthesia holds primary airway responsibility and assessed correlations between experience, confidence, and competency. Methods Fellows were anonymously surveyed regarding their experiences, attitudes, and confidence with airway management. Technical performance was evaluated with simulation using an APCCMPD-derived checklist for direct laryngoscopy (DL), video laryngoscopy (VL), bronchoscopic, and combined-VL-bronchoscopic intubations. Results All 14 fellows (4-40 months of training) completed the survey. Fellows reported a mean of 19.1 (SD 14.7) total intubations with 1.6 (SD 2.4) in the ICU. Five (36%) performed intubations in the ICU, whereas 86% and 79% of fellows performed intubations in the OR and bronchoscopy suite, respectively. Most fellows received didactics, simulation-based training, and OR rotations during fellowship with only 14% of fellows receiving training prior to fellowship. Confidence was highest for bag-valve mask ventilation and bronchoscopy and progressively lower for VL, DL, and salvage techniques. Eleven (79%) fellows completed simulation assessments. Mean completion times for DL, VL, bronchoscopic, and combination intubations were 31s (SD 16s), 34s (SD 8s), 54s (SD 28s), and 63s (SD 24s), respectively. First-pass success occurred in 86% of attempts, five required two passes, and one failed. Overall, 55% of intubations were rated “successful,” and 52% “required significant assistance.” Bronchoscopic intubations received the highest scores, though were not statistically different. Most attempts were rated as “competent with supervision” (86%) or “needs improvement” (14%). Knowledge gaps were notable for medication dosing and equipment preparation. Confidence correlated with total number of intubations (p 0.001) but not with measured performance. 86% of fellows rated their airway training as inadequate, 14% as neutral, and none as adequate. All cited institutional policies as a major barrier to experience, followed by limited procedural opportunities and faculty availability. Fellows reported low confidence in independently managing ICU intubations (mean 1.79, SD 0.94, 1-5-point scale). Conclusions Despite a defined airway curriculum, PCCM fellows at an academic center where anesthesia holds primary airway responsibility demonstrated limited confidence and competence in endotracheal intubation. As confidence did not correlate with success, findings highlight the need for competency-based airway training. This abstract is funded by: None