# Using the predictive model of difficult endotracheal intubation to examine different simulators for airway management training: a pilot cross-sectional observational study

## TL;DR

This study evaluates how well a scoring system predicts the difficulty of endotracheal intubation training using different manikins.

## Contribution

A novel scoring system is proposed to objectively assess the difficulty of airway management training simulators.

## Key findings

- Model C had the highest difficulty score, longest intubation time, and lowest success rate.
- Subsequent intubation attempts showed reduced time and complexity compared to the first attempt.
- The scoring system aligned well with actual training outcomes, supporting its potential use for simulator evaluation.

## Abstract

In recent years, Taiwan’s medical education has increasingly emphasized simulated learning, particularly through advanced manikins designed for procedural training, including endotracheal intubation. Although key indicators and predictive techniques for assessing complexity have been documented, their use in evaluating these manikins remains notably lacking.The aim of this study was to appraise the potential association between our devised scoring system and the actual outcome of intubation procedures. Subsequently, this scoring system could potentially serve as an objective yardstick for quantifying the intricacy of training simulators.

Nineteen post-graduate or emergency medicine trainees participated in this study. Intubation training involved four manikins, each with varying difficulty scores based on neck circumference, thyromental distance, airway obstruction, and Mallampati grade 3/4. Training modules included standard, advanced, and small adult intubation. Independent variables were training models and operator skill levels, while dependent variables included intubation time, success rate, tooth injury, gastric insufflation, uninflated cuff mishaps, perceived difficulty (rated 1–5), and laryngoscopy view quality (rated 1–4).

Intubation parameters were recorded for comparison across subgroups. Mean intubation times for models A, B, and D were 42.67 ± 15.32 seconds, 48.73 ± 17.54 seconds, and 50.22 ± 18.40 seconds, with success rates of 89.47%, 78.95%, and 68.42%, respectively. Model ‘C’ had the highest difficulty score (4.430 points), the longest intubation time (58.84 ± 22.63 seconds, P <.001), and the lowest success rate (57.89%, P <.001), and was rated most difficult by participants. Notably, subsequent intubation attempts showed reduced time and complexity compared to the initial one.In conclusions, our devised scoring metric demonstrated a remarkable congruence with the tangible outcomes of the challenging endotracheal intubation training model. This outcome lends credence to the potential applicability of our formula not only in assessing the intricacy of existing models but also as a guiding benchmark for the innovation and refinement of novel training manikins.

The online version contains supplementary material available at 10.1186/s12909-025-07413-2.