Virtual reality has potential to change airway management training

Virtual reality is being used in medicine to improve airway education and training.

New research presented at the CHEST Annual Meeting demonstrated that the LumetoXR virtual reality (VR) simulation platform was easily adopted by users, showed encouraging efficacy results and yielded strong learner confidence.

“The pandemic brought about a strong need for remote education — to be present without being present,” Ali Hafiz, MD, internist and co-chair of the panel, said in a CHEST press release. “Airway management is of the utmost importance, and this software provides the same team-based approach to decision-making that a physician would experience in a real-life scenario.”

Lumeto, a Toronto-based VR and immersive reality company of specialists focused on education and how these technologies can enhance and evolve training and education in health and safety sectors, partnered with The American College of CHEST Physicians to create a VR platform whereby clinician team members can engage with each other, make decisions and perform procedures on patients to gain new skills and knowledge.

“Cognitive skills [and] scenario-based learning ... are things that have always been the promise of virtual reality, but only now in the last few years has the technology evolved to the point where we think it could have a real impact in the market,” Raja Khanna, Lumeto CEO, co-founder and board chair, said during a presentation.

How it works

Earlier this year, Lumeto developed the InvolveXR VR intubation simulation, informed by CHEST’s curriculum to address the need for safe and effective procedures during the COVID-19 pandemic, according to a company press release. Using CHEST’s APPROACH Checklist for Airway Management, participants are led through the simulation by a remote instructor and are guided through the steps required to perform a successful intubation using video laryngoscopy in an intoxicated patient, according to the release.

In the platform, trainers use their console to operate a scenario, from a 2D screen, and manage and change the scenario and patient attributes and communicate with the learners. On the console, the trainer can observe the learners in the room and show them the bedside monitor for relevant patient vital signs. Intuitive physiology engines allow responses to learner actions including medicine administration and bagging. Trainers can also use their checklist to confirm each critical action performed by the learners and the toggle checklist, which shows the algorithm checklist to the learners during the debriefing session.

“Virtual reality allows for being able to teach beyond the walls of a teaching hospital,” Casey Bryant, MD, said during the session. “It’s about scale – you take your experts at your academic centers and allow them to be able to interface with learners at community hospitals—at other academic centers—and be able to have these fairly intimate learning sessions where it feels like you’re right beside the person when you could be countries away.” 

The learners are in the same virtual ICU even though each individual is physically in separate locations worldwide. In the virtual space, learners can see the other learners, communicate and use spatial audio to perform the procedure.

There are two interaction modes for learners. The first is VR, a one-to-one ratio scale of an ICU where they can interact similarly to in the real world. The second is a flat-screen mode for those without a VR headset. In this mode, learners can participate through regular 2D screens and follow along.

“The major advantage of virtual reality over the traditional hands-on simulation is the ability to do virtual reality sessions remotely, which in the current pandemic is a huge potential advantage,” Brian Kaufman, MD, professor of anesthesiology, internal medicine and neurosurgery at the NYU Grossman School of Medicine, said during the presentation.

Pilot study

The research pilot study was institutional review board approved with three institutions and was conducted during the COVID-19 pandemic with remote learners. The study included 39 physicians, advanced nurse practitioners, respiratory therapists, physician assistants, fellows-in-training and residents from Mayo Clinic, NYU and Wake Forest University.

The aim was to evaluate the VR platform’s usability, efficacy and learner satisfaction.

Up to three learners participated in each pilot session and performed onboarding to introduce themselves to the VR platform and become comfortable with the environment and controllers. Then, learners were separated into different virtual rooms with an airway team leader who determined the roles and responsibilities of each individual.

When the scenario began, the group would manage the intubation process of an intoxicated patient with various difficult airway indicators twice with changing learner roles between each session and an instructor moderating via a computer monitor in a different area. Following each scenario, the instructor completed a debriefing, and a separate faculty member would grade the leader and team on their success.

Average time of the session was 25 minutes.

Although 56% of participants had no prior VR experience, 96% reported being comfortable in the VR platform. Almost all participants succeeded in completing the intubation process.

All participants completed a pretest of 11 questions prior to the simulation and a 12-question posttest regarding airway assessment, difficult airway recognition, proper patient positioning, pharmacology and crisis resource management principles. Test scores increased from 74% to 86% correct after the simulation for all participants.

Participants also responded to a surgery regarding the efficacy of the session:

• 97% were able to describe risk factors, physical examination findings and clinical situations associated with a difficult airway;
• 94% of learners were able to demonstrate a systematic approach to patient evaluation, plan development with appropriate equipment selection and preparation of preoxygenation, and drug selection and utilization prior to intubation; and
• 100% were able to demonstrate effective management of patients with difficult airways and use crew resource management principles to utilize an airway management team to maximize success and patient safety during intubation.

Results showed no difference in learner understanding across different experience levels, ages and previous VR experiences. Researchers also observed no technical difficulties during the simulation.

“We recognize that these observed improvements will need to be further validated, and also compared with other types of remote learning,” Kaufman said. “It was encouraging to see the greatest increase in the pre- to posttest scores in the less experienced learners with the greatest improvement of 26% in resident learners.”

These results provide support for considering VR-based airway management training earlier in clinical experience.

“I’m excited that people see this as a potential tool for training, and I get excited by the idea that places that don’t have access to simulation center or have limited access to unique or rare cases, could potentially use this technology as a way to practice skills and learn skills,” Khanna said.

According to Khanna, full results of this pilot study are scheduled for publishing in the near future.

Barriers, future directions

There are several barriers to overcome before widespread adoption of VR in medical education and training, according to the speakers.

One barrier is the stigma that VR is not an acceptable replica for physical tools or haptic feedback. Addressing that barrier, Khanna noted that the InvolveXR platform focuses on cognitive skills and learning how to make better decisions, better communicate and think about scenarios more effectively.

Technical barriers will also need to be overcome, such as language processing, which is hypothesized to evolve in the near future via possible artificial intelligence-driven doctors or respiratory therapists in the VR platform.

Adoption of this new VR technology continues to be a barrier in different environments. However, Khanna said, prices for VR headsets decrease, inclusion of VR in medical training may be more widely adopted.

“All in all, it is an early adoption phase, but when you see results like that, and you can really train and learn new skills in 25 minutes, I think this technology will find a place in the market,” Khanna said.

Editor’s Note: On Nov. 11, 2021, the article was updated to add an additional quote from Dr. Bryant and further details about the use of the virtual reality platform.