The COVID-19 pandemic has accelerated advancements and adoption of remote training technology, with one novel area being virtual reality simulation used in critical care to improve airway management.

By Lisa Spear

Image: Lumeto’s Involve XR software. Photo contributed by Lumeto.

As Facebook announces plans to roll out a virtual reality universe, the Metaverse, healthcare institutions across the country are already one step ahead and have launched training programs in virtual reality, where respiratory therapists can collaborate with colleagues on difficult airway management cases from any location. 

Alone with an Oculus headset, respiratory therapists have gathered with physicians and nurses to practice intubation in virtual emergency rooms. Paramedics, who could be halfway around the world from each other, feel as if they are together in an ambulance as they ventilate a neonate in distress. These are just a few of the many scenarios that can unfold through software programs like SimX, Oxford Medical Simulation, or InvolveXR, and that are growing in popularity.  

Adaptation to the Pandemic

When simulation labs shuttered due to COVID, the American College of Chest Physicians (Chest) looked to develop novel education programs, with a particular interest in virtual reality. In collaboration with Chest, clinicians at three universities—New York University, the Mayo Clinic, and Wake Forest University—partnered with the company Lumeto to create a virtual reality workspace to train clinicians in airway management. 

Each institution conducted an experiment to explore how effective virtual reality is at educating clinicians. Each participant was stationed alone in a room, but then transported to a virtual space, with the help of an Oculus headset, where they could gather with colleagues. Within that space, they could interact with each other, hear the vital sign monitors, and practice intubation on a patient avatar. Overall, the experiment, and resulting multi-center study, proved to be a success, said Brian Kaufman, MD, a co-investigator and critical care physician at NYU Langone in New York City. “Most people have enjoyed this experience,” he said. 

The idea for the experiment took root when COVID forced Chest’s in-person airway management courses at its Illinois headquarters to stall. The simulation center, home to the $75,000 manikin used to practice airway management techniques, closed its doors. Other simulation centers also ceased in-person operations at a time when airway management education became all the more critical. Since then, virtual reality and augmented reality, have gained traction in healthcare training. The results of the experiment, presented at the annual Chest meeting, found that a single 25-minute virtual reality session led to a 16% relative increase in procedural knowledge across all learners and 26% relative increase in procedural knowledge in residents in the management of a difficult airway.

“The pandemic brought about a strong need for remote education—to be present without being present,” said Ali Hafiz, MD, co-chair of the recent Chest panel presentation. “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.”

Still, Kaufman said, there are ways that these virtual reality programs could improve: The tactile sensations of intubation are not yet replicable, for example. “The one thing that virtual reality is not good at is the actual putting the laryngoscope in the mouth and then putting the tube in. It doesn’t solve that issue because you have to be able to hold the laryngoscope in your hand,” said Kaufman. “There is a feel to lifting up the mouth. There is a lot of resistance.”

Developing Virtual Reality Simulation

In the future, the haptics of virtual reality might become more refined, but for now, it is a supplement to in-person simulation labs, not a replacement. And as tech giants such as Apple, Microsoft, and Facebook enter the virtual reality space, the technology is primed to evolve quickly, said Raja Khanna, CEO, and co-founder at Lumeto, the creator of InvolveXR.

So far, we are already seeing startling innovation take shape. The virtual reality simulation company SimX, for instance, can recreate scenarios, including how to treat a stroke patient, how to handle a patient with chest pain, or how to resuscitate a pediatric patient. SimX can also create customized cases in a few weeks. 

Clinicians during a virtual reality session using Lumeto’s Involve XR software. Photo contributed by Lumeto.

While there are companies that offer pre-packaged virtual reality medical training programs, some medical centers are opting to create their own. 

The Mayo Clinic in Minnesota, for instance, received a grant from Microsoft to develop augmented reality for airway management training during the pandemic, said Thom Belda, an enterprise technology architect for the experiential learning division at the Mayo Clinic and a former pediatric respiratory therapist. 

In partnership with MSR–Israel Center for Medical Simulation at Sheba Medical Center in Israel, the Mayo Clinic developed a 3-D hologram of a Hamilton mechanical ventilator.

After obtaining computer-aided design (CAD) files from the medical device company, Hamilton, the medical centers were able to create the hologram. Trainees could then use the Microsoft HoloLens 2 to learn how to change mechanical ventilator filters. 

By using intuitive hand gestures, like those used when zooming in and out on a smartphone, trainees could see the parts of the ventilator in close detail and even break the machine open to explore the inner mechanisms. The hologram floats in front of them, in their actual environment, hence why the experience is called augmented reality. This tool became particularly critical during the pandemic. “That allowed training to occur for staff that had no experience working with Hamilton ventilators but gave them the comfort level to work with a simulated version in 3-D,” said Belda. “The capabilities of augmented reality really helped others to see the benefit of using it in an actual healthcare environment.”

In another experiment conducted at the Mayo Clinic, clinicians wanted to see if they could teach neonatal intubation via virtual reality. The single-center prospective pilot study compared knowledge retention in learners who underwent a virtual reality 360° immersive experience and those who saw a video of an in-person demonstration of intubation using a Mannikin. The study, which will be published in the coming months, took place over two weeks and set out to investigate the effectiveness of virtual reality as a teaching tool.

With a Garmin VIRB 360 camera mounted on his head, Chris Bosley, RRT, RRT-NPS, LRT, RCP,  pediatric respiratory care education specialist at the Mayo Clinic, recorded the virtual reality experience. The camera uses fisheye lenses to stitch the recording into a sphere to give the participant the feel of actually being within a space. When using an Oculus headset, the learners then have the perspective of someone conducting an intubation. 

“It’s as real as it gets,” explains co-investigator Donnchadh O’Sullivan, MB, BCh, BAO, MRCPI, a second year pediatric resident at Mayo Clinic. Within the recording, Bosley, who is also an instructor in anesthesiology, reviews skill techniques and training procedures on Premature Anne, a realistic and life-like doll that they were able to borrow from the NICU.

“What I found surprising is that there was no significant difference in intubation success between these live demonstrations and these 360° videos when it came to skill acquisition,” said O’Sullivan. “Overall, people really liked it. There was a lot of positive feedback. One of the respiratory therapists said it was the coolest thing she had done in RT.”

Pediatric Applications of Virtual Reality Simulation

Chris Bosley records a VR intubation session at the Mayo Clinic. Photo contributed by Chris Bosley.

Virtual reality training in pediatric airway management is, for some, a particularly important area to explore. Pediatric airway emergencies are relatively uncommon but can have devastating consequences. “Simulation based education is important in providing zero-risk management experience for these critical events,” explains Elizabeth Putnam, MD, a clinical assistant professor of anesthesiology at the University of Michigan, and her collaborators, in a recent research paper.1

The study looked at how HoloLens could simulate a pediatric critical airway event. A randomized group of participants either managed a foreign body aspiration case or an anaphylaxis case. Most areas of knowledge showed improvements following the virtual reality simulations. Specifically, questions on pediatric anatomy, anaphylaxis, and Heimlich maneuver showed the highest score improvements. 

“Interactive videos, in combination with a VR experience, provide promising zero-risk training for pediatric critical airway events,” the authors explain. 

Virtual reality and augmented reality can also bypass some of the limitations of in-person training. Typically, “to get experiential learning today, you have to be in a simulation lab, or you have to be in a cadaver lab, or you have to be physically somewhere with some complicated and expensive equipment around you. Plus, you have to get a trainer to be there with you, so there are a lot of limitations,” said Khanna.

“So this tech, we believe, can create the opportunity to increase the amount of experiential learning that these people get. It is not about taking anything away from simulation labs, it is about adding something,” he said. “If you are a student in a dorm room at university, you can practice intubation or patient airway management from your room with an instructor. And the instructor might be on another campus, or they might be halfway around the world.”

“Now, that student can practice in a virtual environment and it feels like you are really there.”


Lisa Spear is associate editor of RT. For more information, contact [email protected].


  1. Putnam EM, Rochlen LR, Alderink E, Augé J, Popov V, Levine R, Tait AR. Virtual reality simulation for critical pediatric airway management training. J Clin Transl Res. 2021 Feb 2;7(1):93-99. PMID: 34104812; PMCID: PMC8177020.