Learning curve and proficiency attainment in preterm airway endoscopy: a simulation-based study comparing neonatologists and medical students

Background Flexible airway endoscopy is a valuable adjunct for neonatal airway assessment and confirmation of endotracheal tube placement. However, patient vulnerability and the low frequency of these procedures in routine care restrict opportunities for clinical training. Simulation offers a safe environment for skill acquisition. This study aimed to characterize the learning curve of preterm airway endoscopy and compare proficiency attainment between experienced neonatologists and novice medical students.

Methods We conducted a prospective, simulation-based observational study involving 39 participants (13 neonatologists and 26 medical students). Participants performed a standardized airway visualization task on a preterm airway manikin using a flexible micro-endoscope. Following standardized instruction (Peyton's four-step approach) and two familiarization attempts, each participant completed 12 assessed trials and a retention session 7-14 days later. Success was defined as stable visualization of the vocal folds within 180 seconds without critical errors; competence was defined as three consecutive successful attempts. We measured time-to-task completion for visualization of the aryepiglottic folds (TTS1) and vocal folds (TTS2). Learning curves were analyzed using the Learning Curve-Cumulative Sum (LC-CUSUM) method (po =0.20 p1=0.50).

Results All participants completed the study protocol. Inter-rater reliability was high for procedural success (kappa=0.80) and competence attainment (kappa≈1.00). Time measurements demonstrated excellent reliability (ICC single measures 0.94; 95% CI 0.93-0.95). LC-CUSUM analysis indicated progressive skill acquisition, with participants in both groups achieving competence after repeated attempts. The incidence of critical errors was negligible in both groups (experts 0 [IQR 0-0] vs. students 0 [IQR 0-1], p=0.074). Procedure duration did not differ significantly between groups (TTS1: 20 s vs. 18 s, p=0.15; TTS2: 31 s vs. 33 s, p=0.27). Participants reported similar perceived procedural ease and maintained performance levels at the retention session.

Conclusions Preterm airway endoscopy is a learnable skill that can be effectively acquired through simulation training. Despite differing levels of prior clinical experience, medical students achieved performance levels comparable to neonatologists. These findings support the integration of simulation-based training to introduce minimally invasive airway techniques into neonatal care.

DOI: 10.1186/s12909-026-10372-x