Preparedness and education in airway management

Teaching Airway Management Using Virtual Reality: A Scoping Review

Airway management, a defined procedural and cognitive skillset embracing routine tracheal intubation and emergency airway rescue, is most often acquired through an apprenticeship model of opportunistic learning during anesthesia or acute care residency training. This training engages a host of modalities to teach and embed skill sets but is generally time- and location-constrained. Virtual reality (VR)-based simulation training offers the potential for reproducible and asynchronous skill acquisition and maintenance, an advantage that may be important with restricted trainee work hours and low frequency but high-risk events. In the absence of a formal curriculum from training bodies-or expert guidance from medical professional societies-local initiatives have filled the VR training void in an unstructured fashion. We undertook a scoping review to explore current VR-based airway management training programs to assess their approach, outcomes, and technologies to discover programming gaps. English-language publications addressing any aspect of VR simulation training for airway management were identified across PubMed, Embase, and Scopus. Relevant articles were used to craft a scoping review conforming to the Scale for quality Assessment of Narrative Review Articles (SANRA) best-practice guidance. Fifteen studies described VR simulation programs to teach airway management skills, including flexible fibreoptic bronchoscopic intubation (n = 10), direct laryngoscopy (n = 2), and emergency cricothyroidotomy (n = 1). All studies were single institution initiatives and all reported different protocols and end points using bespoke applications of commercial technology or homegrown technologic solutions. VR-based simulation for airway management currently occurs outside of a formal curriculum structure, only for specific skill sets, and without a training pathway for educators. Medical educators with simulation training and medical professional societies with content expertise have the opportunity to develop consensus guidelines that inform training curricula as well as specialty technology use.

Teaching airway teachers: a post-course quantitative and qualitative survey

BACKGROUND

Airway management is a crucial skill for many clinicians. Besides mastering the technical skills of establishing a patent airway, human factors including leadership and team collaboration are essential. Teaching these human factors is often challenging for instructors who lack dedicated training. Therefore, the European Airway Management Society (EAMS) developed the Teach-the-Airway-Teacher (TAT) course.

METHODS

This online post-course survey of TAT-course participants 2013-2021 investigated the impact of the TAT-course and the status of airway management teaching in Europe. Twenty-eight questions e-mailed to participants (using SurveyMonkey) assessed the courses' strengths and possible improvements. It covered participants' and workplace details; after TAT-course considerations; and specifics of local airway teaching. Data were assessed using Excel and R.

RESULTS

Fifty-six percent (119/213) of TAT-participants answered the survey. Most were anaesthetists (84%), working in university level hospitals (76%). Seventy-five percent changed their airway teaching in some way, but 20% changed it entirely. The major identified limitation to airway teaching in their departments was "lack of dedicated resources" (63%), and the most important educational topic was "Teaching non-technical skills" (70%). "Lecturing " was considered less important (37%). Most surveyed anaesthesia departments lack a standardized airway teaching rotation. Twenty-one percent of TAT-participants rated their departmental level of airway teaching overall as inadequate.

CONCLUSIONS

This survey shows that the TAT-course purpose was successfully fulfilled, as most TAT-course participants changed their airway teaching approach and did obtain the EAMS-certificate. The feedback provided will guide future TAT-course improvements to advance and promote a comprehensive approach to teaching airway management.

Simulation in airway management teaching and training

There is a gradual shift in training and teaching methods in the medical field. We are slowly moving from the traditional model and adopting active learning methods like simulation-based training. Airway management is an essential clinical skill for any anaesthesiologist, and a trained anaesthesiologist must perform quick and definitive airway management using various techniques. Airway simulations have been used for the past few decades. It ensures active involvement, upgrading the trainees' airway management knowledge and skills, including basic airway skills, invasive procedures, and difficult clinical scenarios. Trainees also learn non-technical skills such as communication, teamwork, and coordination. A wide range of airway simulators are available. However, texture surface characteristics vary from one type to another. The simulation-based airway management training requires availability, understanding, faculty development, and a structured curriculum for effective delivery. This article explored the available evidence on simulation-based airway management teaching and training.

Exchange of a Tracheal Tube and Supraglottic Airway Device: Evaluation of Different Techniques in Three Simulated Airway Scenarios (TUBE Study)-A Prospective, Randomised Controlled Study

BACKGROUND

The swapping of a supraglottic airway device or a tracheal tube in anaesthetised adult patients is a challenging procedure because potential complications through hypoxemia and loss of airway may occur, with life-threatening implications. This study aims to evaluate which airway technique offers the highest success rate concerning a secure airway in established supraglottic airway and tracheal tube airway exchange scenarios.

METHODS

After ethical approval, anaesthesiologists were randomised 1:1 into simulated scenarios: an LTS group (malpositioned laryngeal tube) and a Cuff group (relevant cuff leakage of a placed tracheal tube). After that, both groups completed a common scenario consisting of a partially obstructed tracheal tube lumen in a fixed prone position with a Mayfield clamp. The primary endpoint was a successful tracheal airway exchange within ten minutes after the start of the scenario and before severe hypoxemia (SpO2 < 80%) arose. Secondary endpoints were the evaluation of factors influencing success after 10 min.

RESULTS

In total, 60 anaesthesiologists (LTS group n = 30; Cuff group n = 30) with a median experience of 7 years (IQR 4-11) were observed. Within 10 min, a malpositioned laryngeal tube was successfully exchanged by 27/30 (90%) participants, compared to the exchange of a tracheal tube with a relevant cuff leakage by 29/30 (97%; p > 0.05). An airway exchange in an obstructed tube scenario occurred in 22/59 (37%). Loss of airway maintenance showed an obvious association with failure in the common scenario (p = 0.02).

CONCLUSION

The results of this simulation-based study reflect that the exchange of an existing but insufficient airway device in clinical practice is a high-risk procedure. Especially in a fixed prone position, the deliberate evaluation of the existing airway patency and well-conceived airway management in the case of the accidental loss of the airway or obstructed airway access are crucial.

[Difficult Airway Management (DAM) Algorithms - A narrative synopsis and site assessment]

Centuries ago an "algorithm" was originally inaugurated to depicture a pathway to solve mathematical problems using a decision tree. Nowadays this tool is also well established in clinical medicine. Ever since management errors in difficult airway handling and subsequent litigations remain high referring to ASA closed claims database. However, even since 2010, the ESA postulates every institution dealing with airway management should have a DAM algorithm (ESA Declaration of Helsinki on Patient Safety in Anaesthesiology). In 2018 a systematic review of 38 international DAM algorithms was published; most of them show a four-step flow chart: failed tracheal intubation, insufficient bag-mask ventilation and supraglottic airway, leads to establish an emergency sugical airway. In conclusion authors state that a universal, globally valid, DAM algorithm is lacking. German language guideline development is governed by the AWMF, which labels guidelines with the highest evidence levels and methodological strength "S3". The ASA published a revised DAM practice guideline in 2022, which was developed by 13 international members and was endorsed by international anesthesiological societies. - Though it is based on a systematic literature search and evaluation, final recommendations (without grading) were generated by a survey among experts in the field: Pre-procedural evaluation of the airway is essential; meanwhile more data are available especially regarding ultrasound examination of the upper airway and in 2022 a promising nomogram was developed for the prediction of difficult laryngoscopy. Pre-procedural planning of expected DAM: it should be decided beforehand, if awake intubation is feasible for the patient. Preoxygenation of every elective patient (3 mins with PEEP 5 cmH₂O, aim: 95% pulse oxymetry) and continuous nasal high-flow oxygen delivery during airway management. In case of unexpectedly difficult/emergency airway, ASA recommends: call for help, use cognitive aid (algorithm), consider restoration of spontaneous breathing, adjust bag-mask ventilation, monitor time passing; if "cannot intubate, cannot oxygenate" situation occurs (etCO₂ < 10 mmHg, < 80% pulse oxymetry) establish surgical airway; if failed consider ECMO therapy, if feasible and available. ASA restricts intubation attempts to 3+ based on experience and decision of the clinician, however evidence shows, that attempts should not exceed 2 attempts to avoid serious complications, e.g. hyoxemia and even cardiopulmonary resuscitation (CPR). Additionally, we recommend a cockpit strategy for airway management using crisis resource elements as used in aviation (situation awareness, sterile communication, read-back/hear-back and canned decisions) and a supervisor/team leader as already established in CPR. Last, but not least, continuous airway management training increases algorithm adherence.

Anesthesiologists' airway management expertise: Identifying subjective and objective knowledge gaps

BACKGROUND

Failure in airway management continues to cause preventable patient harm, and the recommended continuing education is challenged by anesthesiologists' unknown knowledge gaps. This study aimed to identify anesthesiologists' subjective and objective knowledge gaps as well as areas where anesthesiologists are incorrect and unaware.

METHODS

An adaptive E-learning program with 103 questions on adult airway management was used for subjective and objective assessment of anesthesiologists' knowledge. All anesthesiologists in the Capital Region of Denmark were invited to participate.

RESULTS

The response rate was 67% (191/285). For preoperative planning, participants stated low confidence (subjective assessment) regarding predictors of difficult airway management in particular (69.1%-79.1%). Test scores (objective assessment) were lowest for obstructive sleep apnea as a predictor of difficult airway management (28.8% correct), with participants being incorrect and unaware in 33.5% of the answers. For optimization of basic techniques, the lowest confidence ratings related to patient positioning and prediction of difficulties (57.4%-83.2%), which agreed with the lowest test scores. Concerning advanced techniques, videolaryngoscopy prompted the lowest confidence (72.4%-85.9%), while emergency cricothyrotomy resulted in the lowest test scores (47.4%-67.8%). Subjective and objective assessments correlated and lower confidence was associated with lower test scores: preoperative planning [r = -.58, P < .001], optimization of basic techniques [r = -.58, P = .002], and advanced techniques [r = -.71, P < .001].

CONCLUSION

We identified knowledge gaps in important areas of adult airway management with differing findings from the subjective and objective assessments. This underlines the importance of objective assessment to guide continuing education.

Maintaining competence in airway management

BACKGROUND

Airway management is a defining skill for anaesthesiologists. Anaesthesiologists must maintain and update these crucial skills throughout their career, but how this is best achieved remains unclear. This study aimed to clarify anaesthesiologists' procedural volume, confidence in airway management and their current and preferred future educational strategies.

METHODS

A questionnaire was developed consisting of 28 items exploring essential skills in airway management. All anaesthesiologists in the Capital Region of Denmark were invited to participate.

RESULTS

The response rate was 84% (240/285). Most anaesthesiologists felt competent to a high or very high degree in basic airway management. Anaesthesiologists from anaesthesia felt confident to a significantly higher degree than those working in the intensive care unit (ICU) regarding the practical aspects of airway management in both the anticipated difficult airway (93% vs 73%, P < .001) and the unanticipated difficult airway (81% vs 61%, P = .002). Both groups performed most of the key advanced techniques ≤4 times yearly, whereas anaesthesiologists from the ICU had a lower and less diverse procedural volume than those working in anaesthesia. The anaesthesiologists preferred training through their daily clinical work, hands-on workshops, and scenario-based simulation training. However, a large discrepancy was identified between the current and the desired level of training.

CONCLUSION

The anaesthesiologists felt competent to a high or very high degree in basic airway management but the current procedural volume in advanced airway management causes concern for skill maintenance. Furthermore, we found a gap between the current and the desired level of supplemental training.

Procedural Training and Assessment for Pediatric Emergency Medicine Physicians Within the United States and Canada: A Survey Study

OBJECTIVES

The aims of this study were to determine current practices in procedural training and skill assessment for attending physicians working in pediatric emergency departments within the United States and Canada and identify barriers to providing training and assessment.

METHODS

This was a cross-sectional survey study. Members of the pediatric emergency medicine fellowship program directors and associate program directors Listserv were invited to participate in an anonymous survey about attending physician training and assessment practices for 9 specific procedures and barriers to training and assessment.

RESULTS

Eighty-two (56.2%) of 146 recipients responded, with 79 surveys fully completed; 58.5% of responders report that their division offers procedural training, whereas 14.6% report assessment of procedural skills. The most common procedure for which participants report training and assessment is orotracheal intubation (53.1% and 7.5%, respectively), with training rates for other procedures ranging from 2.5% to 43.0%. Most sites that report training use simulation in some form for education. For assessment, simulation is used almost exclusively. Cost (50.6%), lack of faculty interest (36.7%), and lack of standardized guidelines (36.7%) are the most common barriers to training. Lack of standardized guidelines (51.9%), cost (43.0%), and lack of faculty interest (38.0%) are the most common barriers for assessment.

CONCLUSIONS

Although pediatric emergency medicine physicians may be required to perform emergent procedures, opportunities to receive training and assessment in these procedures are limited. Simulation and other educational modalities are being used to provide skill training and assessment, but cost and lack of resources, standardized protocols, and faculty interest are barriers to the implementation of training and assessment programs.

Advanced airway training in the UK: A national survey of senior anesthetic trainees

Background and Aims:

High-quality training in advanced airway skills is imperative to ensure safe anesthetic care and develop future airway specialists. Modern airway management skills are continually evolving in response to advancing technology and developing research. Therefore, it is of concern that training provisions and trainee competencies remain current and effective.

Material and Methods:

A survey questionnaire based on the airway competencies described in the Royal College of Anaesthetists’ curriculum and Difficult Airway Society guidelines was posted to all United Kingdom (UK) National Health Service hospitals to be completed by the most senior anesthetic trainee (ST 5–7, resident).

Results:

A total of 149 responses were analyzed from 237 hospitals with eligible anesthetic trainees (response rate 63%), including 53 (36%) and 39 (26%) respondents who had completed higher and advanced level airway training respectively. Although clinical experience with videolaryngoscopy was satisfactory, poor confidence and familiarity was identified with awake fiberoptic intubation, high frequency jet ventilation, at risk extubation techniques, and airway ultrasound assessment. Only 26 (17%) respondents had access to an airway skills room or had regular airway emergency training with multidisciplinary theater team participation. Reported barriers to training included lack of training lists, dedicated teaching time, experienced trainers, and availability of equipment.

Conclusions:

This national survey identified numerous deficiencies in airway competencies and training amongst senior anesthetic trainees (residents) in the UK. Restructuring of the airway training program and improvements in access to training facilities are essential to ensure effective airway training and the capability to produce future airway specialists.

Guidelines and algorithms for managing the difficult airway

The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms.