INTRODUCTION: Flexible bronchoscopic intubation (FBI) is an important technique in managing an anticipated difficult airway, yet it is rarely performed and has a steep learning curve. We aim to evaluate if the integration of virtual reality gaming application into routine FBI training for emergency department doctors would be more effective than traditional teaching methods. METHODS: We conducted a randomised controlled trial to compare self-directed learning using the mobile application, Airway Ex* in the intervention group versus the control group without use of the mobile application. All participants underwent conventional didactic teaching and low-fidelity simulation with trainer's demonstration and hands-on practice on a manikin for FBI. Participants randomised to the intervention arm received an additional 30 minutes of self-directed learning using Airway Ex, preloaded on electronic devices while the control arm did not. The primary outcome was time taken to successful intubation. RESULTS: Forty-five physicians (20 junior and 25 senior physicians) were enrolled, with male predominance (57.8%, 26/45). There was no difference in time taken to successful intubation (median 48 seconds [interquartile range, IQR 41-69] versus 44 seconds [IQR 37-60], P=0.23) between the control and intervention groups, respectively. However, the intervention group received better ratings (median 4 [IQR 4-5]) for the quality of scope manipulation skills compared to control (median 4 [IQR 3-4], adjusted P=0.03). This difference remains significant among junior physicians in stratified analysis. CONCLUSION Incorporating virtual reality with traditional teaching methods allows learners to be trained on FBI safely without compromising patient care. Junior physicians appear to benefit more compared to senior physicians.

INTRODUCTION: Intubations in the emergency department (ED) are often performed immediately without the benefit of pre-selection or the ability to defer. Multicentre observational data provide a framework for understanding emergency airway management but regional practice variation may exist. We aim to describe the intubation indications, prevalence of difficult airway features, peri-intubation adverse events and intubator characteristics in the ED of the National University Hospital, Singapore. METHODS: We conducted a prospective observational study over a period of 31 months from 1 March 2016 to 28 September 2018. Information regarding each intubation attempt, such as indications for intubation, airway assessment, intubation techniques used, peri-intubation adverse events, and clinical outcomes, was collected and described. RESULTS: There were 669 patients, with male predominance (67.3%, 450/669) and mean age of 60.9 years (standard deviation [SD] 18.1). Of these, 25.6% were obese or grossly obese and majority were intubated due to medical indications (84.8%, 567/669). Emergency physicians' initial impression of difficult airway correlated with a higher grade of glottis view on laryngoscopy. First-pass intubation success rate was 86.5%, with hypoxia (11.2%, 75/669) and hypotension (3.7%, 25/669) reported as the two most common adverse events. Majority was rapid sequence intubation (67.3%, 450/669) and the device used was most frequently a video laryngoscope (75.6%, 506/669). More than half of the intubations were performed by postgraduate clinicians in year 5 and above, clinical fellows or attending physicians. CONCLUSION In our centre, the majority of emergency intubations were performed for medical indications by senior doctors utilising rapid sequence intubation and video laryngoscopy with good ffirst-attempt success.