I hear and I forget
I see and I remember
I do and I understand
—Confucius, 551-479 BC

Simulated experiences have become a popular standard in health care education and training over the last several years.1-3 The use of simulation-based education in health care allows for hands-on experience and manipulation of equipment, as well as the application of critical thinking components not possible in traditional classroom learning. In simulation cases, a lifelike mannequin is placed in a realistic patient environment and a health care provider evaluates and treats the patient. Simulation attempts to replicate a real event and provide a foundation for learning, understanding, and practice.

Respiratory therapists are a vital component of the pediatric health care team. Data from 72 simulated pediatric medical crises (“mock codes”) held at our institution from 2004 to 2010 reveal that in 52% of code situations, bag valve mask (BVM) ventilation is provided by a respiratory therapist.4 Management of the pediatric airway can be challenging, given the variety of sizes and congenital and anatomic variables. Simulation can be an important training tool to practice skills such as BVM ventilation and intubation, as well as team skills such as patient handoffs and communication.

The simulation experience is dependent on a successful integration of the environment, suspension of disbelief, facilitators, and postsimulation debriefing. The debriefing is essential, as it allows learners to reflect on the experience and often results in significant learning. It is an open discussion, where learners have the opportunity to understand, analyze, and synthesize information with the objective of improving future performance. Goals of debriefing include maintaining a confidential and supportive environment while providing time to explore reactions to the case, developing an understanding of what occurred, reviewing what was learned, and receiving feedback.5

Simulation-based learning provides no risk to patients and is a safe, structured environment designed to be realistic to the learner. Participants can also be exposed to uncommon or rarely experienced events, thereby standardizing curriculum. Distracting family members or malfunctioning equipment can often add significant complexity to simulation cases. Simulation facilitators are convinced of the power of simulation-based education by virtue of the visible impact on participants. Active research is being conducted in a variety of health care disciplines to uncover evidence for simulation learning.

Course Description

The Respiratory Care Department and the Pediatric Simulation Center at Children’s Hospital in Birmingham, Ala, developed the pediatric respiratory care course to provide a structured experience for all levels of RTs. The course focused on the role of an RT in pediatric emergent and code situations and aimed to provide entry-level knowledge and skills for less experienced therapists while remaining challenging for advanced therapists. Classes were offered bimonthly over the course of a year, and were limited to three therapists per session. Each class was 90 minutes in length and included three scenarios with three simulators of different ages, each intended to emphasize a certain set of skills and critical thinking. Each scenario was intended to build on the skills of the previous scenario and could be altered in degree of difficulty, depending on the experience of the learner. The opportunity for multidisciplinary communication and teamwork was included in each scenario.

Course Objectives
  1. Apply critical thinking skills
  2. Demonstrate assessment of the pediatric patient in common scenarios requiring respiratory therapy intervention
  3. Apply knowledge of pediatric situations involving respiratory therapy management
  4. Demonstrate prompt recognition and intervention in pediatric treatment scenarios as a respiratory therapist
  5. Anticipate, suggest, prepare, and assist with treatment modalities
  6. Analyze and respond appropriately to blood gas results
  7. Identify and administer pediatric respiratory pharmacologic interventions in various simulations
  8. Practice pediatric manual skills such as airway positioning, BVM, cricoid pressure, preparing intubation equipment, insertion of airway adjuncts, confirming and securing ETT placement, and other indicated procedures
  9. Utilize crisis resource management skills
  10. Communicate and plan with multidisciplinary team members using SBAR
  11. Gain improved understanding of the defined scope of respiratory therapy responsibilities in code situations
  12. Improve respiratory therapy confidence and composure in emergency life-threatening situations

For successful completion of this course, participating pediatric RTs were required to recognize and respond to three pediatric emergencies requiring respiratory therapy management in a simulated environment. Participants demonstrated knowledge of pediatric airway management, including performing or assisting with advanced skills such as oxygen therapy, airway adjuncts, BVM ventilation, and intubation. Emphasis was placed on RT assessment and management of the pediatric patient requiring intervention. Team management and communication was also a component of each scenario.

After each simulation, scenario debriefing reviewed key teaching points and airway skills such as BVM ventilation, assisting with intubation, and securing endotracheal tube (ETT) placement at the proper location. Debriefing staff included pediatric experts in critical care, emergency medicine, and respiratory therapy. Video recordings of the simulation were used during debriefing sessions to provide constructive feedback to participants.

The course began with a 15-minute introduction in which key portions of the Emergency Airway Management Protocol (see Figure) were highlighted, as well as calculations for determining ETT size and depth, institutional method of securing the ETT, and SBAR (Situation, Background, Assessment, Recommendation) communication.6 The therapists then participated in three 15-minute scenarios, each followed by a 15-minute debriefing.

Scenario #1 Resolving Apnea

A 6-week-old, former 34-week gestation premature infant with Pierre Robin sequence. The respiratory therapist is called by the bedside nurse after a brief observed apneic event. When the RT arrives, the infant has resumed spontaneously breathing, but apnea recurs with associated oxygen desaturation and bradycardia requiring BVM ventilation and the use of an oral airway. Spontaneous respirations do not return, and appropriate personnel must be notified for intubation. Communication issues: efficient but complete patient handoff, the process of escalating care, and calling the code team. Debriefing points include a review of proper BVM technique, the use of cricoid pressure, BVM with congenital airway malformations, and appropriate rates of ventilation in pediatric patients, as well as patient handoffs and escalation of care.

Scenario #2 Hypoventilation

A 9-year-old patient with scoliosis who is 2 days postoperative from a posterior spinal fusion and has developed lower oxygen saturations. The bedside RN calls for RT assistance secondary to increasing oxygen requirement from 1 to 4 LPM via nasal cannula. The patient has been receiving scheduled pain medication and is now difficult to arouse. An arterial blood gas analysis reveals significant respiratory acidosis secondary to hypoventilation due to narcotic administration. The RT should recognize hypoventilation and suggest a narcotic antagonist while assisting respirations with BVM ventilation. The RT also needs to notify appropriate personnel to prepare for intubation if the condition is not easily reversible. Communication issues: the arrival of the rapid response team and the need for a patient handoff summary. Debriefing includes blood gas interpretation, SBAR report to physician, selection of appropriate sized intubation equipment, and sequence of events for unplanned intubation in an inpatient acute care area.

Scenario #3 Respiratory Failure with Cardiopulmonary Arrest

A 16-year-old with a recent diagnosis of myasthenia gravis admitted to the inpatient unit. Respiratory therapy is called for an increase in oxygen requirement from 1 to 3 LPM via nasal cannula. The patient has recently finished a cough assist treatment and now complains of severe difficulty breathing. The rapid response team is activated. The patient continues to deteriorate, resulting in a cardiopulmonary arrest, recovering only after intubation and resuscitative efforts. Communication issues: transition of care with the arrival of the code team. Debriefing for this case includes the RT’s role in a code event, communication in a critical or code event, and review of respiratory items on the code cart.

Results and Discussion

Eighteen RTs attended the course. Feedback was overwhelmingly positive, with all expressing satisfaction with the teaching method and level of material. All participants agreed that the course was applicable to their profession and was a valuable experience that improved both their comfort and skill level with pediatric patients. This course was a successful integration of simulation-based education with the educational needs of a diverse pediatric respiratory therapy department.

This application of adult learning principles is appropriate for novice to expert learners. Adult learners are generally self-directive when they can appreciate why they should know certain information, make use of prior experience, and choose what they want to take from a learning experience.7,8 Simulation allows learners to be active participants in the educational process. The activation of learners can improve the long-term retention of knowledge.9 Psychomotor skills can be enhanced through hands-on practice and repetition. Simulation can also be useful in teaching communication techniques, teamwork, and leadership skills.

Simulation allows the learner to assess a patient, formulate and provide an appropriate plan of care, and reassess patient outcomes. Novices, as well as experienced practitioners, can benefit by improving their critical thinking and by receiving immediate feedback about their patient care decisions. Degrees of difficulty of simulation scenarios can easily be increased or decreased to tailor an experience to fit learner needs.

The realism of the scenario can be accomplished through degrees of fidelity. Low fidelity simulation generally offers limited interaction with the learner and includes cardiopulmonary resuscitation mannequins and task trainers such as intubation heads. The spectrum of simulation also includes high-fidelity mannequins, which provide immediate feedback to practitioners through visible breathing, palpable pulses, and changing vital signs. The degree of fidelity necessary is dependent on the objectives of the experience for the learner. If the goal is to demonstrate and practice the motor skills of intubation, intubation heads are acceptable. To include the cognitive and decision-making skills involved in the intubation, a higher fidelity mannequin that can better replicate a patient with impending respiratory failure may be preferable.

Unfortunately, simulation is not without barriers to use. Budget and space constraints may be limiting. Technology may be difficult to master and assimilate into existing program curricula. Scenario programming and debriefing techniques may be a time-consuming skill set to achieve. Even inexpensive, lower-fidelity simulation can contribute to health care provider education when accompanied by proper debriefing techniques, however.


High-fidelity simulation provides an excellent arena for medical teams to practice patient care and interdisciplinary collaboration, which has been shown to save lives and increase job satisfaction.10 The implementation of a respiratory therapy course dedicated to improving therapists’ skills in pediatric emergencies appeared to have had a favorable impact at our institution. Future directions include objectively evaluating participants for improved procedural and critical thinking skills outside of the simulation center. It is only when we can document improved patient care outcomes that simulation-based education will come into its own.

Nancy M. Tofil, MD, MEd, is medical director, pediatric simulation center, and associate professor of pediatrics, division of critical care; Julia M. Niebauer, MD, is instructor/fellow, division of critical care, department of pediatrics; Marjorie Lee White, MD, MPPM, MEd, is associate medical director, pediatric simulation center, and assistant professor of pediatrics, division of emergency medicine, University of Alabama at Birmingham. J. Lynn Zinkan, RN, MPH, is simulation nurse educator, pediatric simulation center; Amber Q. Youngblood, RN, BSN, is simulation nurse educator, pediatric simulation center; and Craig Wooten, RRT, BS, is head respiratory therapist, pediatric intensive care unit, Children’s Hospital of Alabama, Birmingham.

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