An audit of airway management equipment in a metropolitan region

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Chapter 4.  Education in airway management

Baker PA, Weller JM, Greenland KM, Riley RH, Merry AF: Education in airway management. Anaesthesia 2011; 66: 101-111


This chapter was a review article in a special edition of Anaesthesia in 2011 devoted to airway management (417). The review relied on a detailed summary of current literature; however, this was not a systematic review. The timing of this publication coincided with the release of the The Fourth National Audit Project of the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) (NAP4) which concluded that deficiencies in education and training were major contributory factors to significant patient morbidity and mortality. As lead author of this review article I researched the subject, wrote the first draft of the paper and supervised all subsequent revisions prior to publication.


Poor judgment, education and training are leading causes of patient morbidity and mortality associated with airway management. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate.
Curriculum change is under way in many medical organisations in an effort to correct these problems and management of the airway is likely to be explicitly addressed as a clinical fundamental within the new anaesthetic curriculum. Competency based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management.
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 cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire to constantly improve performance. Expert airway management by anaesthetists requires a career-long commitment to education and should include knowledge, skill and human factor training.


Inadequate skill and poor judgement in airway management continues to lead to avoidable brain damage and death in occasional patients (3). The expert panel that reviewed 184 cases of major airway complications in The Fourth National Audit Project of the Royal College of Anaesthetists (RCoA) and the Difficult Airway Society (DAS) (NAP4) (3), concluded that poor judgement (59%) and education/training (49%) were the second and third most frequent causal and contributory factors (after patient factors; 77%). Difficult or delayed intubation, failed intubation and ‘cannot intubate, cannot ventilate’ (CICV) situations accounted for 39% of events during anaesthesia. Deficiencies in airway assessment, under-utilization of awake intubation, inappropriate use of supraglottic airway devices (SGAs) and evidence of poor airway management planning were also noted. In a review of litigation related to anaesthesia in National Health Service (NHS) Hospitals in the UK from 1995 to 2007, airway and respiratory related events accounted for 12% of all anaesthesia claims, 53% of deaths and 27% of cost, and were involved in 10 of the 50 most expensive claims (418).
These studies contain important messages which should help direct training in airway management towards improved patient care. Our aim in this review is to assess current training practice and discuss proposals to improve education in airway management in the future.

Traditional approach to learning airway management

“We now accept the fact that learning is a lifelong process of keeping abreast of change. And the most pressing task is to teach people how to learn”.
Peter F. Drucker (419).
The traditional apprenticeship model of medical education, based on experiential learning in the clinical environment, is more than 100 years old (420). The operating room (OR) environment can provide opportunities for safe and deliberate practice of airway technique in patients with varied anatomy, pathology and physiology (421). This has been, and remains, the most common form of training in airway management skills in anaesthesia. Apprenticeship training, however, is ad hoc, with varying and unpredictable exposure to appropriate cases, and consequent safety and ethical issues. Furthermore, opportunities to learn advanced airway skills are diminishing through increased use of the laryngeal mask airway, regional techniques, reduced training hours and pressures on clinical placements (422-424). Care for the patient can be compromised during training in the operating room (OR). The workload of the instructing anaesthetist is increased during teaching, and vigilance may decrease (425). Some exercises devised for OR airway training can, in fact, increase risk and may be considered unethical. These include choosing to place a tracheal tube, when an SGA would otherwise have been selected, to increase learning opportunities; or deliberately limiting the laryngoscopic view to practice more difficult intubations (426-429). Potential for patient harm during this early part of the learning 69 curve, and the question of whether consent from patients is needed, raise important practical and ethical issues (430). Intubation via direct laryngoscopy, for example, is a complex technical skill (431): its success rate is only 50% in novices (432) and a rate of 90% cannot be expected until 50 attempts have been made. Moreover, 18% of trainees still require assistance after 80 attempts (433). The limitations outlined in teaching laryngoscopy affect the time it takes for trainees to achieve an acceptable level of safe, unsupervised practice.
The challenges associated with developing and maintaining airway skills are not restricted to trainees. Many senior anaesthetists will have honed their airway skills on the job, through trial and error. Many are self-taught and have adopted flexible bronchoscopy and the use of SGAs or rigid indirect intubation devices without any formal instruction (223). As senior practitioners, they are assumed to be experts on the basis of their many years of practice. In reality, the quality of technical care tends to deteriorate over years unless regular deliberate practice is maintained (434). In one study, younger anaesthestists out-performed their older colleagues on all categories of measurement when performing cricothyroidotomy (435). Knowledge and skills decay over time, but this decay can be arrested by practice (436, 437). In a national survey of 386 anaesthetists, the average number of fibreoptic intubations performed per year was three for consultants and four for registrars. A paucity of appropriate clinical cases and, therefore, of opportunities for practice, was considered the primary barrier to development of this complex skill (223).
Anaesthetists need to be skilled in a variety of techniques in order to manage a range of clinical presentations (438), but there is a tendency to limit skills to a few core techniques. Several surveys reveal a limited use of intubation techniques other than direct laryngoscopy, and inexperience with awake fibreoptic intubation and cricothyroidotomy (439-441). It is encouraging that the number of techniques and devices available for managing difficult airways has increased dramatically over the last three decades, but this has also made it more difficult to acquire and maintain the broad range of airway skills that might reasonably be expected of an anaesthetist today. Inadequate knowledge contributes to the problem: for example, the ability to identify the cricothyroid membrane (44) or properly understand the Cormack Lehane classification (442).
While standardization of equipment is associated with improved performance and patient outcomes (443), it is infrequently done. New airway devices are often adopted without formal teaching and without practitioners reading instructions (444). Practitioners teach themselves, often without applying best practice (223). This can lead to poor techniques and harm to patients (445, 446). Educators need to improve training in airway management while practitioners’ skills need to be diversified to an adequate level of expertise without harming patients.

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Developing expertise in airway management

Anaesthetists claim to be airway experts, but is this justified? Ericsson argues that while experience is part of being an expert, experience alone does not guarantee expertise. Ericsson has identified consistent behaviours which shape expertise and superior performance in non-medical domains such as sport and music (447). 70
Deliberate practice, immediate feedback, problem-solving and evaluation with the chance to repeat performance and modify behaviour are essential ingredients in the attainment of expert performance (448). These concepts apply equally to the development of airway skills. The learning curve for most airway devices is biphasic: reasonable competence can be achieved within 30 cases, but performance continues to improve even after 100 cases (449). It is during this early phase of learning that individuals pass through the cognitive and associative phases where development is enhanced by teachers, trial-and-error and problem solving. Eventually performance plateaus, procedures become effortless and a state of automaticity is reached. Ericsson cautions that this automaticity can lead to arrested development rather than continuing enhancement of expertise. The danger is that, once a behaviour has become automatic, it is difficult to modify: Ericsson cites the tying of shoelaces as one such automated behaviour. If direct laryngoscopy becomes automated, it may be difficult to modify one’s technique to cope with a rare or unexpected situation. A patient with a difficult airway demands an anaesthetist who has the ability to modify his or her technique as necessary. The risk is that, without deliberate practice, many practitioners will not advance beyond the stage of automaticity, and will perform at a mediocre level for the rest of their careers (Figure 4.1).
Advanced expertise requires increased control over performance. Experts counter arrested development by deliberately and regularly seeking challenges outside their comfort zone as opportunities for deliberate practice. Such practice should be distributed at regular intervals over a prolonged period of time (450). Deliberate practice may be integrated into clinical practice but it can perhaps be more readily obtained in skills laboratories which provide the opportunity to accelerate learning through simulation. For anaesthetists to retain the mantle of airway experts, they need to be constantly striving to improve performance.

Defining the Airway Curriculum

Many organisations involved in training doctors in general, and anaesthetists in particular, have engaged in reviewing their curricula over recent years. Notably, the Australian and New Zealand College of Anaesthetists (ANZCA) is currently undertaking a comprehensive curriculum review (ANZCA Curriculum Redesign Project) (452). A key feature of the revised curriculum of this College is likely to be the identification of clinical fundamentals for anaesthetists, of which airway management is one. The intent is to ensure that anaesthetists achieve and formally demonstrate appropriate levels of competence in a defined set of learning outcomes within these clinical fundamentals at each stage of their training before advancing to the next stage. Airway management will be explicitly addressed within the curriculum, and expected competencies at different stages of training will be defined (Table 4.1), with a series of assessments to ensure these are attained. Initiatives are also being considered by ANZCA to ensure that these essential competencies in airway management are not only acquired in training, but also maintained after graduation as a specialist. Comparable developments have occurred within the Royal College of Anaesthetists.

A staged approach to developing airway expertise

With the advent of airway management as a clinical fundamental within the curriculum, more airway training programmes will be required. Formal programmes in airway management have already been in existence for many years. The number of airway residency programmes in the US and Canada has increased over the last 16 years, and their content and modes of teaching have evolved (453). A graduated system of training which reinforces and expands participants’ existing knowledge and skills is ideal. Course content should follow a syllabus reflecting guidelines and best practices (Table 4.2).
Numerous airway guidelines have been published internationally with varying emphasis and content, and these have been recently reviewed (48, 416). It is important that guidelines are regularly updated, are based on good evidence and are developed in accordance with methodological standards (235), especially if these guidelines are to be used to evaluate a doctor’s practice (454). Courses should include background reading material (which can be provided electronically) to support course content and provide core information. Airway training programmes often depend on institutional support and funding. It is helpful for institutions to appoint coordinators to act as champions for these programmes (455, 456).
A best practice approach should be adopted when teaching skills (180, 457). Techniques and equipment to be included in the training program should comply with guidelines (458) and be reflected in the practices and equipment held in local hospitals. Teaching should take into account the level of expertise of the learner. In an ideal setting novices should start their training on part task trainers in an airway training room, then progress through more sophisticated modalities, perhaps using cadavers or anaesthetised animals, or animal tissue preparations (134, 459-462). They should then progress to clinical training under supervision once they have achieved competence using simulation. Each of these approaches has advantages and disadvantages including cost, the requirement for ethics committee approval and potential morbidity. Awake fibreoptic intubation can be practised on volunteers (463), but we have reservations about subjecting trainees to procedures with a risk of morbidity, even with their permission (374). A comprehensive review of teaching techniques has been provided by Stringer (464).
Understanding the function and limitations of airway equipment is fundamental to safe airway management. The tendency to pick up new devices and work out how to use them from first principles can lead to patient harm. Coroner’s cases have been reported where anaesthetists were unable to assemble emergency equipment (465). Use of improvised emergency equipment can lead to delays in patient care or poor outcomes (219, 405). Guidelines have been published which emphasize standardization of equipment, whilst still providing a range of alternative devices to cope with unusual circumstances, and quality control measures to promote a culture of safety (458). Suggestions have been made to ‘sign off’ practitioners to use new equipment only after they have demonstrated competence in its use (466). Parallels can be found in other clinical areas – for example, approval to perform percutaneous carotid artery stenting is now dependent on relevant simulation-based training by physicians (467).
Video can enhance training, and in particular can help to demystify direct laryngoscopy (468) and fibreoptic intubation . One example of this is the Airway Cam™ Direct Laryngoscopy Video System (Airway Cam Technologies, Inc, Wayne PA USA) which consists of a head mounted camera designed to display the laryngoscopist’s view on a screen for trainees or supervisors to see (469). Airway Cam™ images have been recorded for training digital versatile discs (DVDs) and for hands-on instruction (432, 468). Video can also facilitate assessment with global rating scores (470). A number of studies describe the benefit of imaging the larynx with video laryngoscopes to assist instruction during training in laryngoscopy (471-474).
Advancement of airway skills beyond the proficiency needed for routine anaesthetic practice requires opportunities for dealing with patients whose airways are more challenging. 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 (455). Airway workshops have been in existence for decades (475) and vary in content. They are usually run by enthusiasts and often focus on techniques such as flexible bronchoscopy, cricothyroidotomy or direct laryngoscopy (134, 432, 463). Participants at such workshops report improvements in accuracy and confidence with airway evaluation, adoption of previously unfamiliar airway devices and changes in practice related to managing patients with difficult airways (476). However, unless the learner follows the workshop with ongoing deliberate practice the benefits may be short-lived; providing airway laboratories in the workplace may be an effective way of facilitating this. There is considerable interest in taking simulation to the clinical environment (477).

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The potential for simulation to enhance learning

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.
The range of simulators for use in anaesthesia is wide. As indicated above, certain basic skills can be acquired using very simple simulators (478) while more sophisticated simulators offer opportunities to achieve advanced educational objectives (479). Although part-task trainers can be useful to teach airway techniques such as SGA insertion, direct laryngoscopy and other procedures described in airway algorithms (480, 481), educators should be careful when choosing models and manikins, to ensure that they have adequate fidelity and are fit for purpose. Some manikins have been criticised as unrealistic with poor laryngeal anatomy, rigid structures and inability to simulate reversible airway obstruction (481, 482). There is unequal performance for different types of manikins using various SGAs (483). Training conditions provided by manikins are not necessarily the same as in patients, and the use of some SGAs by novices is more difficult in patients than manikins (484). Careful analysis of training needs should be applied before acquiring appropriate simulators. In order to effectively teach each step of the DAS guidelines, for example, more than one type of airway training model is required (481, 485). An advantage of using a variety of manikins is the finding that trainees tend to adapt their skill to a particular manikin, and therefore providing them with variety of manikins can lead to a broader range of skills (486).
Simulation can compensate for inadequate clinical experience by providing the opportunity to perform multiple repetitions of a procedure over a short period of time. In a study using the Accutouch® flexible bronchoscopy simulator, novice residents performed an average of 17 oral fibreoptic intubations in 39 minutes, and demonstrated significant improvement in clinical dexterity with the flexible bronchoscope after this relatively brief period of training (487). Simulators allow trainees to advance at their own rate and training can be tailored to specific tasks and procedures (433, 488). Simulation may have a role in identifying deficiencies in practitioners and contributing to their retraining (489).
In general, 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. Simulation is usually expensive, and its cost-effectiveness in relation to alternative educational methods has not been well established, although the advantages outlined above may lead to financial savings: for example, training using simulators can reduce repair costs for fibreoptic equipment by up to 84% (490). Standards in relation to simulators and simulation facilities have been slow in coming (491).

Table of contents
Included publications 
Table of contents 
List of figures 
List of tables 
Outline of this thesis 
Chapter 1. Literature review 
1.1. Assessment prior to airway management
1.2. Planning the management of a patient’s airway
1.3. Percutaneous emergency airway access
1.4. Equipment to manage a difficult airway
Chapter 2. An audit of airway management equipment in a metropolitan region
Chapter 3. Equipment to manage a difficult airway during anaesthesia
Chapter 4. Education in airway management
Chapter 5. Thyromental distance measurement – fingers don’t rule
Chapter 6. Airway management during an EXIT procedure for a foetus with dysgnathia complex
Chapter 7. A prospective randomised trial comparing supraglottic airways for flexible bronchoscopy in children
Chapter 8. Failure to ventilate with supraglottic airways after drowning
Chapter 9. An audit of laryngoscopes and application of a new ISO standard.
Chapter 10. Visual acuity during direct laryngoscopy at different illuminance levels
Chapter 11. Parker Flex-Tip or standard tracheal tube for percutaneous emergency airway access? A prospective randomised trial.
Chapter 12. Experimental adaptation of the Enk Oxygen Flow Modulator for potential paediatric use
Chapter 13. How anaesthetists in New Zealand disseminate critical airway information about patients
Chapter 14. Discussion and conclusions 
Appendix index
Improving the Quality and Safety of Airway Management

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