An international survey of airway management education in 61 countries†

Resuscitation following trauma & role of trauma training programmes in emergency settings: A literature review & survey

Background & objectives Traumatic injuries, especially in low- and middle- income countries (LMICs), present significant challenges in patient resuscitation and healthcare delivery. This study explores the role of trauma training programmes in improving patient outcomes and reducing preventable trauma-related deaths. Methods A dual approach was adopted, first a literature review of trauma training in LMICs over the past decade, along with a situational assessment survey. For the review of literature, we searched the PubMed database to identify key challenges and innovative practices in trauma training programmes in LMIC's. The survey, conducted among healthcare professionals in various LMICs, collected direct insights into the challenges and the status of trauma training programmes in these countries. Results The literature review analysed 68 articles, with a significant focus on the African subcontinent (36 studies), underscoring the region's emphasis on research on trauma training programmes. These studies mainly targeted physicians, clinicians, postgraduate trainees in surgical or anaesthesia fields and medical students (86.8%), highlighting innovations like simulation-based training and the cascading training model. In our survey, we received 34 responses from healthcare professionals in India, Belarus, Azerbaijan, Nepal and Pakistan. Around 52.9 per cent reported the absence of established trauma training programmes in their settings. The majority of respondents advocated for hands-on, simulation-based training (94.1%) and emphasised the need for structured training programmes (85.3%), feedback sessions (70.6%) and updated protocols (61.8%). This combined data underlined the critical gaps and potential improvements in trauma training programmes and resuscitation practices in LMICs. Interpretation & conclusions Effective trauma care in LMICs requires the establishment of comprehensive, tailored training programmes. Key interventions should include subsidization of pre-existing trauma courses and the adoption of World Health Organization Guidelines for essential trauma care, implementation of trauma quality improvement and review processes and the incorporation of focused assessment with sonography in trauma (FAST) in emergency departments. These steps are crucial for equipping healthcare workers with vital skills and knowledge, fostering a culture of continuous learning and improvement in the realm of trauma care.

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

Retrograde tracheal intubation using the S-guide intubation guide after emergent tracheotomy: A case report

Retrograde intubation is an historic technique that is now rarely used in difficult airway situations. Although not originally designed for this purpose, the use of an S-guide is a feasible option to aid retrograde intubation because of its malleable rigid body and atraumatic tip.

Videolaryngoscopy use before and after the initial phases of the COVID-19 pandemic: The report of the VL-iCUE survey with responses from 96 countries

BACKGROUND

The potential benefit of videolaryngoscopy use in facilitating tracheal intubation has already been established, however its use was actively encouraged during the COVID-19 pandemic as it was likely to improve intubation success and increase the patient-operator distance.

OBJECTIVES

We sought to establish videolaryngoscopy use before and after the early phases of the pandemic, whether institutions had acquired new devices during the COVID-19 pandemic, and whether there had been teaching on the devices acquired.

DESIGN

We designed a survey with 27 questions made available via the Joint Information Scientific Committee JISC online survey platform in English, French, Spanish, Chinese, Japanese and Portuguese. This was distributed through 18 anaesthetic and airway management societies.

SETTING

The survey was open for 54 to 90 days in various countries. The first responses were logged on the databases on 28 October 2021, with all databases closed on 26 January 2022. Reminders to participate were sent at the discretion of the administering organisations.

PARTICIPANTS

All anaesthetists and airway managers who received the study were eligible to participate.

MAIN OUTCOME MEASURES

Videolaryngoscopy use before the COVID-19 pandemic and at the time of the survey.

RESULTS

We received 4392 responses from 96 countries: 944/4336 (21.7%) were from trainees. Of the 3394 consultants, 70.8% (2402/3394) indicated no change in videolaryngoscopy use, 19.9% (675/3394) increased use and 9.3% (315/3393) reduced use. Among trainees 65.5% (618/943) reported no change in videolaryngoscopy use, 27.7% (261/943) increased use and 6.8% (64/943) reduced use. Overall, videolaryngoscope use increased by 10 absolute percentage points following the pandemic.

CONCLUSIONS

Videolaryngoscopy use increased following the early phase of the COVID-19 pandemic but this was less than might have been expected.

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.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Fibreoptic intubation: a commitment to an indispensable technique

Recent evidence has shown that fibreoptic intubation is still an indispensable technique for safe management of predicted difficult airways, despite the implementation of new technologies such as videolaryngoscopy. It is therefore our obligation as anaesthesia societies and as practicing anaesthetists to offer this technique to our patients in clearly designated situations.

A multicentre neonatal interventional randomised controlled trial of nebulized surfactant for preterm infants with respiratory distress: Neo-INSPIRe trial protocol

INTRODUCTION

Respiratory distress syndrome in preterm infants is an important cause of morbidity and mortality. Less invasive methods of surfactant administration, along with the use of continuous positive airway pressure (CPAP), have improved outcomes of preterm infants. Aerosolized surfactant can be given without the need for airway instrumentation and may be employed in areas where these skills are scarce. Recent trials from high-resourced countries utilising aerosolized surfactant have had a low quality of evidence and varying outcomes.

METHODS AND ANALYSIS

The Neo-INSPIRe trial is an unblinded, multicentre, randomised trial of a novel aerosolized surfactant drug/device combination. Inclusion criteria include preterm infants of 27-34+6 weeks' gestational age who weigh 900-1999g and who require CPAP with a fraction of inspired oxygen (FiO2) of 0.25-0.35 in the first 2-24 h of age. Infants are randomised 1:1 to control (CPAP alone) or intervention (CPAP with aerosolized surfactant). The primary outcome is the need for intratracheal bolus surfactant instillation within 72 h of age. Secondary outcomes include the incidence of reaching failure criteria (persistent FiO2 of > 0.40, severe apnoea or severe work of breathing), the need for and duration of ventilation and respiratory support, bronchopulmonary dysplasia and selected co-morbidities of prematurity. Assuming a 40% relative risk reduction to reduce the proportion of infants requiring intratracheal bolus surfactant from 45 to 27%, the study will aim to enrol 232 infants for the study to have a power of 80% to detect a significant difference with a type 1 error of 0.05.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the relevant human research ethics committees at University of Cape Town (HREC 681/2022), University of the Witwatersrand HREC (221112) and Stellenbosch University (M23/02/004).

TRIAL REGISTRATION

PACTR202307490670785.

Videolaryngoscopy in critical care and emergency locations: moving from debating benefit to implementation

The recently published INTUBE study subanalysis and DEVICE trial findings both demonstrate a clear benefit of videolaryngoscopy over direct laryngoscopy in facilitating tracheal intubation of patients in the emergency department and ICU. We consider the increasing evidence supporting the use of videolaryngoscopy, the possible reasons behind its relatively slow adoption into clinical practice, and the potential role of the hyperangulated videolaryngoscope blade. We discuss the significance of improved first-pass tracheal intubation success in reducing the overall risk of complications in critically ill patients. Additionally, we address the need for specific training in videolaryngoscopy in order to maximise patient benefit, and propose that adequate training and rehearsal opportunities in videolaryngoscopy can only be realised by widespread and regular use wherever the clinical setting.

Current practice pattern among anaesthesiologists for difficult airway management: A nationwide cross-sectional survey

Background and Aims

The practice patterns for airway management vary among anaesthesiologists, depending on various setups and geographical divides. This survey assessed practice patterns in unanticipated difficult intubation and cannot intubate or cannot ventilate (CICV) situations/complete ventilation failure among Indian anaesthesiologists'.

Methods

A validated questionnaire of 22 items related to practice preferences for airway management among anaesthesiologists was sent to Indian Society of Anaesthesiologists members online through Google Forms and distributed manually to delegates in continuing medical education programme.

Results

A total of 535 responses were obtained and analysed. In unanticipated difficult laryngoscopy and intubation, the order of preference for alternative airway devices was video laryngoscope (VL, 60.1%), intubating laryngeal mask airway/laryngeal mask airway (23.5%), fibreoptic bronchoscope (13.5%) and optical stylets (1.2%). Advanced difficult airway devices were unavailable in most nursing homes and government non-teaching hospitals. Seventy per cent of respondents experienced CICV situations at least once, most during head and neck surgeries. In CICV situations, the order of choice for the front-of-neck airway access was cricothyroidotomy (CT) by narrow bore cannula (48.9%), tracheostomy by the surgeon (30%), Seldinger CT (12.5%), open surgical CT (5.4%) and scalpel bougie CT (3.2%).

Conclusion

The VL was the most preferred airway rescue device in unanticipated difficult intubation, and intravenous catheter cricothyroidotomy was the most selected technique in CICV situations.

Airway Management: The Current Role of Videolaryngoscopy

Airway management is usually an uncomplicated and safe intervention; however, when problems arise with the primary airway technique, the clinical situation can rapidly deteriorate, resulting in significant patient harm. Videolaryngoscopy has been shown to improve patient outcomes when compared with direct laryngoscopy, including improved first-pass success at tracheal intubation, reduced difficult laryngeal views, reduced oxygen desaturation, reduced airway trauma, and improved recognition of oesophageal intubation. The shared view that videolaryngoscopy affords may also facilitate superior teaching, training, and multidisciplinary team performance. As such, its recommended role in airway management has evolved from occasional use as a rescue device (when direct laryngoscopy fails) to a first-intention technique that should be incorporated into routine clinical practice, and this is reflected in recently updated guidelines from a number of international airway societies. However, currently, overall videolaryngoscopy usage is not commensurate with its now widespread availability. A number of factors exist that may be preventing its full adoption, including perceived financial costs, inadequacy of education and training, challenges in achieving deliverable decontamination processes, concerns over sustainability, fears over "de-skilling" at direct laryngoscopy, and perceived limitations of videolaryngoscopes. This article reviews the most up-to-date evidence supporting videolaryngoscopy, explores its current scope of utilisation (including specialist techniques), the potential barriers preventing its full adoption, and areas for future advancement and research.

Prehospital Airway Management for Trauma Patients by First Responders in Six Sub-Saharan African Countries and Five Other Low- and Middle-Income Countries: A Scoping Review

The global injury burden disproportionately affecting low- and middle-income countries (LMICs) is exacerbated by a lack of robust emergency medical services. Though airway management (AM) is an essential component of prehospital emergency care, the current standard of prehospital AM training and resources for first responders in LMICs is unknown. This scoping review includes articles published between January 2000 and June 2021, identified using PMC, MEDLINE, and SCOPUS databases, following PRISMA-ScR guidelines. Inclusion criteria spanned programs training formal or informal prehospital first responders. Included articles were assessed for quality using the Newcastle-Ottawa scale. Relevant characteristics were extracted by multiple authors to assess prehospital AM training. Of the initial 713 articles, 17 met inclusion criteria, representing 11 countries. Basic AM curricula were found in 11 studies and advanced AM curricula were found in nine studies. 35.3% (n = 6) of first responder programs provided no equipment to basic life support (BLS) AM training participants, reporting a median cost of $7.00USD per responder trained. Median frequency of prehospital AM intervention was reported in 31.0% (IQR: 6.0, 50.0) of patient encounters (advanced life support trainees: 12.1%, BLS trainees: 32.0%). In three studies, adverse event frequencies during intubation occurred with a median frequency of 22.0% (IQR: 21.0, 22.0). The training deficit in advanced AM interventions in LMICs suggests BLS AM courses should be prioritized, especially in sub-Saharan Africa. Prehospital AM resources are sparse and should be a priority for future development.

Formation of an Airway Lead Network: an essential patient safety initiative

We outline the history, implementation and clinical impact of the formation of an Airway Lead Network. Although recommendations to improve patient safety in airway management are published and revised regularly, uniform implementation of such guidelines are applied sporadically throughout the hospital and prehospital settings. The primary roles of an Airway Lead are to ensure supply, quality and storage of airway equipment, promote the use of current practice guidelines as well as the organisation of training and audits. Locally, the Airway Lead may chair a multi-disciplinary airway committee within their organisation; an Airway Lead Network enables Airway Leads to share common problems and solutions to promote optimal airway management on a national level. Support from governing bodies is an essential part of this structure.

Emergency medicine airway leads: a rapid response distributed educational model for emergency department COVID-19 airway management

With the first case of COVID-19 confirmed in Canada in early 2020, our country joined in the fight against a novel pathogen in a global pandemic. The stress of uncertainty and practice change was most apparent in the emergency department when it came to managing known or suspected COVID-19 patients requiring airway management. Recognizing the need for a coordinated approach, a province wide rapid response distributed model of continuing professional development for airway management was developed utilizing Airway Leads to help prepare front-line medical personnel providing airway management for these patients. Airway Leads worked with local physicians to deliver consistent, high quality airway education across the province during the initial surge of cases. Education included both in person and virtual sessions along with real time ongoing support through provincial guidelines, videos, and other documents. Physician reported “stress level” pre- and post-Airway Lead support declined from a median score of 9 to 7 (on a 10-point Likert Scale).

Airway Leads and Airway Response Teams: Improving Delivery of Safer Airway Management?

Purpose of Review

Airway management remains a source of significant morbidity and mortality. This review considers recent summaries of complications and looks toward strategies to improve practice using a coordinated approach.

Recent Findings

A safety gap can exist between national recommendations and local practice. A lack of attention to end tidal carbon dioxide has repeatedly contributed to airway mismanagement. Clinicians must be trained in newer airway devices (videolaryngoscopes or supraglottic airways) to use them effectively. Time must be found to teach rarely performed skills (e.g., front-of-neck access). Both larger and smaller hospitals have benefitted from an airway lead or response team, coordinating education programs, ensuring the adoption of guidelines, standardizing equipment, and recognizing the role of human factors and ergonomics.

Summary

Even in the twenty-first century, the incidence of airway-related morbidity and mortality can be reduced, by an institutionally supported, coordinated approach to the whole process of airway care.