|Year : 2019 | Volume
| Issue : 1 | Page : 28-35
Teaching and training in airway management: Time to evaluate the current model?
Joanne Spaliaras, Agathe Streiff, Glenn Mann, Tracey Straker
Department of Anesthesiology, Montefiore Medical Center, New York, USA
|Date of Web Publication||25-Apr-2019|
Dr. Joanne Spaliaras
Department of Anesthesiology, Montefiore Medical Center, 111 E 210th Street Bronx, New York
Source of Support: None, Conflict of Interest: None
Management of the airway is central to the practice of anaesthesiology and yet surveys reveal that trainees frequently feel poorly trained in this area. Good skills in airway management include not only technical proficiency with an increasingly complex and wide range of equipment but also the clinical judgement and experience to use them appropriately. Lapses in judgement, education and training are leading causes of patient morbidity and mortality. It is now more imperative than ever for anaesthesiology training programmes to carefully review their curricula and evaluate the educational tools being used for effective advanced airway education of the next generation of airway specialists. Residency programmes have also seen the need to incorporate a formalised airway rotation into their curricula. One to 2-year long airway fellowships are now being advocated to provide the trainee a unique opportunity to master the advanced clinical knowledge and techniques necessary to successfully manage the most challenging clinical scenarios in airway management. It is essential for educators and practitioners alike to consider innovative models of training, advancing and retaining of skills. Such advanced skills can ensure the safe airway management and delivery of quality care to patients of all ages and medical complexity. Before preparation of the manuscript, a PubMed and Cochrane search of the scientific literature published in the past 10 years with the terms 'anesthesiology training', 'airway management education' and 'advanced airway management skills' was conducted.
Keywords: Advanced airway management skills, airway management education, anesthesiology training
|How to cite this article:|
Spaliaras J, Streiff A, Mann G, Straker T. Teaching and training in airway management: Time to evaluate the current model?. Airway 2019;2:28-35
|How to cite this URL:|
Spaliaras J, Streiff A, Mann G, Straker T. Teaching and training in airway management: Time to evaluate the current model?. Airway [serial online] 2019 [cited 2019 Jun 17];2:28-35. Available from: http://www.arwy.org/text.asp?2019/2/1/28/257045
| Introduction|| |
Airway management is at the core of anaesthesiology practice and airway training is one of the key elements that residents need to master during their anaesthesiology teaching programme. Failure to maintain adequate gas exchange can be catastrophic and may have important medicolegal implications. Good skills in airway management include not only technical proficiency with an increasingly complex and wide range of equipment but also the clinical judgement and experience to use them appropriately.
An expert panel review of major airway complications in the Fourth National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society concluded that poor judgement and education/training were the second and third most frequent causal and contributory factors (after patient factors). Difficulty or delay in securing an airway, failed intubation and 'cannot intubate, cannot ventilate' situations accounted for 39% of events during anaesthesia. NAP4 identified several recurring themes in instances of airway complications including deficiencies in airway assessment, underutilisation of awake intubation, inappropriate use of supraglottic airway device and evidence of poor airway management planning in the face of potential difficulty. This seminal audit of major complications of airway management is the largest ever performed and has influenced airway management worldwide. Similarly, respiratory adverse events leading to anaesthesiology malpractice claim account for a large proportion of claims for death and brain damage in the American Society of Anesthesiologists (ASA) Closed Claims database.
In recent years, the discipline of anaesthesiology has become inundated with recommendations and practice guidelines on airway management in an effort to mitigate the extrinsic contributory factors of catastrophic patient outcomes. Although there is no gold standard in managing a difficult airway, minimum standards have been set forth that can be expected from a medical practitioner in a given clinical situation. In 1990, the ASA formed the Task Force on Management of the Difficult Airway in response to the Closed Claims database findings.
The product of that task force was the ASA 1993 'Practice Guidelines for Management of the Difficult Airway'. These guidelines delineated recommendations for evaluation of the airway, basic preparation for difficult airway management and a strategy for intubating the difficult airway centred around a difficult airway algorithm (DAA). Since their inception, the practice guidelines have undergone two revisions. The dissemination of these guidelines encourages airway practitioners to consider their strategies and formulate specific plans for the management of a predicted or unexpected difficult airway.
The different algorithms and guidelines are highly variable due to the lack of an optimal technologic solution for all difficult airway scenarios. The continued proliferation of airway devices designed to aid management of the difficult airway has the potential to improve patient outcomes. Specific airway management techniques are greatly influenced by individual disease and anatomy, and successful management may require a combination of devices and techniques. It is now more imperative than ever for anaesthesiology training programmes to carefully review their curricula and evaluate the educational tools being used for effective advanced airway education in the next generation of airway specialists.
In airway management, lapses in judgement, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education with a reliance on experiential learning in the clinical environment is inconsistent and often inadequate. Many medical organisations have instituted airway management curriculum changes in an effort to address and correct these problems. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to handle a variety of clinical presentations. Mastery in a technique requires reflective and repeated practice in increasingly novel and challenging situations. Expertise stems from deliberate practice and a career-long commitment to education and improved performance.
| Current Status of Training and the Needs and Challenges to Such Training|| |
The Accreditation Council for Graduate Medical Education (ACGME) sets guidelines for anaesthesiology trainees to demonstrate competency in 'a broad spectrum of airway management techniques, to include laryngeal masks, fiberoptic intubation and lung isolation techniques, such as double-lumen endotracheal tube placement and endobronchial blockers'. The guidelines further state that this training must involve the care of 40 patients. Despite an abundance of literature discussing the importance of training in airway management and a wealth of research regarding how training can best be achieved, most surveys of training practice reveal concerning deficiencies.
Competence in airway management requires mastery of a broad range of skills, from face mask ventilation to fibreoptic intubation. Opportunities to learn advanced airway skills are diminishing secondary to increased use of supraglottic devices, regional techniques, reduced training hours and pressures on clinical placements. Videolaryngoscope further decreases the opportunities for flexible fibreoptic management of the difficult airway. In reality, the accuracy of technical skills tends to deteriorate over years unless regular deliberate practice is maintained. In one study, younger anaesthesiologists outperformed their older colleagues on all categories of measurement when performing cricothyroidotomy. Knowledge and skills decay over time, but this decay can be halted by practice.
Paucity of appropriate clinical cases and thus of opportunities for practice was considered the primary barrier to skill development. As airway experts, anaesthesiologists need to be skilled in a variety of airway techniques to manage an array of clinical presentations, but there is a tendency to limit skills to a few core techniques. Surveys similarly reveal a limited use of intubation techniques other than direct laryngoscopy and inexperience with awake fibreoptic intubation and cricothyroidotomy. While the number of techniques and devices available for managing difficult airways has increased dramatically over the past three decades, these advancements have also made it more difficult to acquire and maintain the broad range of airway skills that might reasonably be expected of an anaesthesiologist today.
The traditional model of medical education in which learning depends on exposure to clinical cases of varying difficulty has advantages of managing actual anatomy, physiology and pathology in different complex scenarios. While this method of experiential learning has its supporters, it is not without flaws. There is an inconsistent clinical exposure to complex patients, with patient safety implications arising when novice trainees are working on patients, and workload increases on the instructing anaesthesiologist in the operating room.
Didactic teaching in conjunction with other modalities certainly plays an important role. There is a basic core of knowledge that is necessary before a new procedure is attempted, and classroom teaching or independent reading is important in this regard. In a Danish survey, only 17% of 36 anaesthesiology residents were reported to be successful in a written examination on a 'cannot intubate-cannot ventilate' scenario. Of all the participants, 97% had difficulty in applying the ASA-DAA and 53% did not know how to oxygenate through the cricothyroid membrane. The serendipitous clinical exposure to complex patients may also be demonstrated from a report by Cormack and Lehane that an anaesthesiologist performing 200 tracheal intubations per year comes across only 32 Grade III difficult intubation cases within 12 years. The incidence of Grade III intubation has been found to be 1.3% for every 100 intubation practices performed by the residents. It means that 27% of the residents never face a Grade III case in their first 100 intubation practices. These problems call for a re-examination of the current practice in education in airway management. A thorough and multilayered education and training plan is thus essential. Simulation-based medical education has been presented as an effective option to complement traditional clinical experiences.
Simulation provides a way of teaching and evaluating technical and cognitive skills (including skills related to human factors) outside the operating room, without risk to patients and away from the pressures of clinical work. This can serve as a valuable tool to enhance learning. Simulation can further compensate for inadequate clinical experience by providing the opportunity to repetitively perform a procedure over a short period of time.
Advantages of simulators include the ability to allow trainees to advance at their own rate and training. Practicing advanced airway management skills within this context is felt to improve technical, cognitive and team-working performance if similar situations are encountered in real life. Furthermore, simulation may have a role in identifying deficiencies in practitioners and contribute to their retraining. Simulation in anaesthesia has high face validity and participants tend to enjoy simulation-based education, but improvement in patient outcome consequent to its use in training is not well established. The effectiveness of simulation training requires well-defined assessment parameters and trained evaluators. Simulation is usually expensive and its cost-effectiveness in relation to alternative educational methods has not been well established. Advantages outlined above may lead to financial savings as, for example, training using simulators may reduce repair costs for Fibreoptic equipment by up to 84%. In a systematic review and meta-analysis published in The Journal of the American Medical Association, Cook et al. concluded that in comparison with no intervention, technology-enhanced simulation training in health professions education is consistently associated with large effects for outcomes of knowledge, skills and behaviours and moderate effects for patient-related outcomes.
A re-evaluation of current training models is important in the light of the increasing complexity of adult patients as well as the unique challenges that the paediatric patient population poses. Children under the care of an anaesthesiologist have more airway-related adverse events than adults. The NAP4 study reported only ten events in children younger than 10 years, four of which were related to difficult intubation. These findings brought to light a knowledge gap about the efficacy of various indirect tracheal intubation methods in children-related complications and their risk factors.
In comparison to adults, management of the normal and difficult airway in paediatric patients has different challenges. Young children have anatomic, physiologic and cooperative differences that often make airway management approaches used in adults inapplicable. Children have higher oxygen consumption rates compared to adults and their rate of arterial oxygen desaturation when apnoeic is consequently much faster. Subtle differences in assessing the neonatal and infant airway may also be missed and lead to an unanticipated difficult airway.
Recent data suggest a difficult laryngoscopy incidence of 3.9%, 4.5% and 1.2% in neonates (age < 29 days), infants (29 days until the end of the 1st year of life) and toddlers (from the 2nd year to the 5th year of life), respectively. In addition, a subset of paediatric patients with known syndromes such as Pierre Robin, Treacher Collins and Beckwith–Wiedemann syndrome are likely to present with difficulty in ventilation and intubation. These patients often require advanced techniques to manage the airway. Syndromes associated with a difficult airway can even persist into adulthood.
In a large prospective, multicentre study published by Fiadjoe et al. in 2016 that addressed the established vulnerability of children during airway management, it was estimated that difficult tracheal intubation occurred in 2–5 per 1000 paediatric anaesthesia cases in large academic centres in the United States. This study also showed that 20% of children with difficult tracheal intubations had a complication.
Fellowship training in paediatric anaesthesiology is essential in developing expertise in paediatric airway management and some may argue that an additional rotation in advanced paediatric airway training is also necessary. Studies show that children <1 year of age have a higher risk of difficult airway. Failure in airway management is a common cause of hypoxic brain damage, cardiopulmonary arrest and death in children. The American Academy of Pediatrics recommends that paediatric patients with elevated risk should be managed by anaesthesiologists who are graduates of a paediatric fellowship training programme or have continuous competence in care of such patients. To further skill acquisition, trainees need ample opportunity for deliberate practice, repetitive performance, problem solving and immediate feedback. These educational endeavours offer trainees the understanding and procedural skills to make critical decisions in airway management and achieve expert competency.
Future directions begin with institutional and national standards for paediatric airway management and education. The creation of formal hospital 'airway consultation services' (comprised of multidisciplinary airway specialists who coordinate training, develop guidelines and standardise and incorporate new equipment) will improve preparedness and patient safety.,
Residency programmes have seen the need to incorporate a formalised airway rotation into their curricula. In a 2009 survey, Pott et al. cited that 49% of all the residency programmes that were surveyed had a formalised airway rotation. This figure was up from a 2003 survey that cited 33%. The advantage of structured training in the form of designated 'airway blocks' or programmes has been discussed. Many airway management educators argue that an abbreviated intense airway management block training is not sufficient to prepare the resident in the management skills and techniques that significant technological advances in head-and-neck surgery now necessitate. The advancement of airway skills beyond the proficiency needed for routine anaesthetic practice requires opportunities for dealing with patients whose airways are more challenging. This becomes more poignant when one considers that head-and-neck patients comprised ∼ 40% of the cases with airway-related complications and nearly 75% of cases where an emergent surgical airway was required in the 'cannot intubate-cannot ventilate' situation in the NAP4 study.
Airway fellowships provide such opportunities and also allow senior trainees to engage in relevant research, teaching and the development of advanced clinical skills. Graduates from such fellowships serve as a resource to promote and provide education in airway management. One to 2-year long fellowships are being advocated to provide the trainee a unique opportunity to master the advanced clinical knowledge and techniques necessary to successfully manage the most challenging clinical scenarios in airway management. The education of specialised practitioners should include deliberate practice and learning and should aim for expertise rather than mere competence.
There are currently only four airway fellowship programmes or combined airway and head-and-neck anaesthesia programmes in the United States. Fewer than ten fellows trained in airway management/head-and-neck anaesthesia graduate each year in the United States. There is thus great opportunity and need for more such programmes both in the United States and abroad.
An essential element of any airway curriculum is an assessment. Some training programmes require trainees to record their experience in logbooks, but self-reported logbooks are often unreliable and their validity as a tool for assessing competence has not been well established. Airway fellowships could provide further opportunity for the development of validated assessment tools and expert faculty development in education to optimise trainee learning. Another component of faculty development is the ability to give feedback. Feedback is essential to help trainees identify and remedy gaps in performance and to reinforce positive behaviours. Periodic assessment and recertification of competency are reasonable expectations in competency-based approaches to training and the maintenance of skills.
| The Future of Airway Management Education – Challenges and Needs|| |
Since the time of the survey of anaesthesiology residency programmes in the United States and Canada by Pott et al. in 2011, airway management education has been impacted by several changes – transitions in classes of airway devices, evolution of complexity of surgeries and paradigm shifts in airway management education.
Compared to anaesthesiology residents from a decade ago, present residents are more likely to be trained and dependent on videolaryngoscopy for the majority of anticipated and unexpected difficult airway scenarios. This trend is likely to be a reflection of institutional cultures and emphasis on the reduction of attempts at direct laryngoscopy and prioritising videolaryngoscopy in anticipated difficult airways in the DAA by the ASA.
Concerns have emerged regarding the education and retention of direct laryngoscopy skills including the use of straight blades. Contemporary educators may circumvent this problem while reducing the number of direct laryngoscopy attempts by encouraging the learner to initially obtain a direct view of the larynx prior to relying on the video screen. This approach simultaneously promotes direct laryngoscopy skill acquisition while allowing the educator to provide high-quality real-time feedback using the video screen. In this regard, videolaryngoscopy may be viewed as an asset in the present and future of airway management education. Similarly, rarely used rescue devices such as intubating supraglottic device insertion and jet ventilation will pose a challenge to educators and may need to be performed in the elective setting.
Of greater concern is the decrease in skillset of awake fibreoptic intubation techniques. In 2011, a survey of the United States and Canadian anaesthesiology residency programmes found that only 34% of anaesthesiology residents reported to performing at least 25 awake fibreoptic intubations while in training. This number has likely decreased since the study publication, in part due to the convenience and efficacy of videolaryngoscopy. Nevertheless, the awake fibreoptic technique remains one of the most crucial airway management techniques, and efforts must be made to retain these skills amongst future providers by creating an operating room culture and an educational system that values exposure to awake fibreoptic intubation technique. Educators must not lose the motivation to learn and teach the use of alternative airway devices.
Other techniques at risk for clinical extinction due to their invasive nature, high risk-to-benefit ratio, cumbersome setup or more readily available alternatives include optical stylets, retrograde intubation, blind nasal technique, awake intubation, rigid fibreoptic, transtracheal puncture with jet ventilation and cricothyroidotomy. Over the past three decades, once-novel devices such as the supraglottic airways and videolaryngoscope have increased in their prominence in airway society algorithms. Clinician educators should continue to expect newer airway management technology to appear at similarly rapid rates.
Otolaryngology procedures have also evolved significantly placing an increased demand on the airway management skills of the contemporary anaesthesiologist. These complex surgeries require teamwork and coordination between the otolaryngologist and the anaesthesiologist, not only for airway management but also for intraoperative anaesthetic management and postoperative extubation planning. Further airway management challenges arise when these patients return for non-otolaryngology procedures. Airway management education during residency must adapt to meet these unique airway challenges that even in academic centres continue to pose high risk.
The modalities of airway management education are similarly evolving. There is a shift from apprentice style, 'learn by doing' instruction to an increasing role for simulation prior to or in conjunction with direct patient experiences. Airway management education faces inherent challenges – the high anxiety of the situation may add an emotional and stress factor to the clinician educator and resident learner. The learner, when placed in this scenario, must rapidly conceptualise the other components of airway management including technical and human skills in a time-sensitive fashion. Patient acuity may preclude adequate and detailed instruction, compromising the educational potential of this experience. In this respect, simulation-based education has played a crucial role serving a purpose not only in primary knowledge acquisition but also in long-term continuing education. Grande et al. argue that airway training and education consists of three distinct components – technical, methodological and behavioural. While emphasis is traditionally placed on the learner's technical skills, group competencies such as situational awareness, leadership and effective teamwork merit dedicated teaching. The authors encourage the acquisition of these components in designated simulation centres prior to bedside learning, although this may not always be possible in the rigid clinical schedule of graduate medical education. Nevertheless, there is evidence to support simulation as an effective learning tool for airway management education, more so in nontechnical milestones than outcomes or time skill.,
The traditional modalities of airway education are well described and will continue to be significant components of airway management education, including printed reading materials and a formal, structured airway rotation. The survey by Pott et al. reported that 86% of anaesthesiology residency programmes required formal case logs for difficult airways. This figure is likely approaching 100% due to mandated case logs and reporting requirements by the ACGME. These logs are an opportunity to further assess airway management exposure of the resident and to seek to fill any knowledge gaps.
Despite the requirement for minimum case logs, a standardised curriculum for airway management does not currently exist. There are no data to support a minimum number of cases needed to be considered an expert in airway management. Straker addressed this question in 2014 and likewise also concluded that there does not appear to be a minimum amount of procedures to confer competency in airway management.
Expert opinion such as that of the Society for Head and Neck Anesthesia (SHANA) Education Board emphasises the importance of structured difficult airway training. SHANA enumerates learning objectives in this aim. The implementation of an airway curriculum includes not only year-specific educational goals and techniques (such as anatomy, physiology, direct laryngoscopy and supraglottic devices for CAY-1; skills using fibreoptic and other intubation aids for CAY-2 and jet ventilation and apnoeic oxygenation techniques for CAY-3) but also the development of a faculty interested in acquiring and transmitting these skills.
In addition to an effective curriculum to teach airway management skills, accurate assessment tools must be developed. Specifically, future developments should include the creation of an objective, standardised assessment, including ratings for successful technique, decision-making skills, time taken to successfully secure airway, competency in self-reflection and debriefing and maintenance of education. [Table 1] is an example of a stratified airway rotation curriculum at one institution. Opportunities for research include aggregate and data-driven evidence of the efficacy of these educational curricula in increased patient safety.
| Conclusion|| |
Management of the airway is central to the practice of anaesthesiology and yet surveys reveal that trainees frequently feel poorly trained in this area. The goal of medical education is to create well-rounded practitioners who are equipped with the skills and knowledge to safely manage patients with difficult airways. While there is currently no evidence to support one set of airway management guidelines over another as a gold standard, there is consensus on several aspects of difficult airway management, including the importance of a preemptive airway assessment when feasible, a requirement for the development of skill with advanced airway techniques and the need for a preplanned airway management strategy that culminates with surgical airway.
If anaesthesiologists are to continue to be held in high regard as airway management experts, it is impingent on educators and practitioners alike to consider innovative models of training, advancing and retaining of skills. Safe airway management and the delivery of quality care to patients of all ages and medical complexity require preemptive planning, deliberate practice, technical mastery of advanced airway skills, and the motivation for lifelong learning.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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