Education and training in airway management

Anesthetic challenges in difficult airway in a patient with maxillary carcinoma: A case report

Airway management in patients with maxillary carcinoma presents unique challenges. To ensure safety, a tailored and collaborative approach is essential. This is a case where anesthetic plan of awake fiberoptic oral endotracheal intubation was chosen.

Assessing clinical reasoning in airway related cases among anesthesiology fellow residents using Script Concordance Test (SCT)

INTRODUCTION

Clinical reasoning is a core competency for physicians. In the field of anesthesia, many situations require residents to use their clinical reasoning to make quick and appropriate decisions such as during emergency airway cases. The Script Concordance Test (SCT) is a test developed in recent years and validated that objectively assess clinical reasoning ability. However, studies involving SCT to assess clinical reasoning in airway management is scarce.

AIM

To evaluate SCT in assessing clinical reasoning for airway management in anesthesiology residents.

METHOD

A cross-sectional study involving residents and anesthesiology consultants from the Department of Anesthesiology and Intensive Care, Faculty of Medicine Universitas Indonesia was conducted to complete SCT. A panel of five anesthesiology consultants with more than 15 years of work experience constructed 20 SCT vignettes based on prevalent airway cases in our center from the past 10 years. Each SCT has three nested questions, with a total of 60 questions, to be answered within 120 min.

RESULTS

The SCT of 20 case vignettes with three nested questions were tested on 99 residents from the junior, intermediate, and senior residents, compared to answers from the expert group consisting of ten anesthesiology consultants with more than 5 years of experience. There were significant differences in mean SCT scores in the junior, intermediate, senior and expert groups, 59.3 (46.1-72.8), 64.7 (39.9-74.9), 67.5 (50.6-78.3), and 79.6 (78.4-84.8); p < 0,001 consecutively. Cronbach Alpha 0.69 was obtained, indicating good reliability.

CONCLUSION

Our SCT was proven to be a valid and reliable test instrument to assess the clinical reasoning in airway management for anesthesiology residents. SCT was able to discriminate between groups of different clinical experiences and should be included to evaluate airway competencies in anesthesiology residents.

Formalin-free soft embalming of human cadavers using N-vinyl-2-pyrrolidone: perspectives for cadaver surgical training and medical device development

The traditional apprenticeship approach to surgical skill education for young surgeons has drastically changed to more systematic surgical training using cadavers. Cadavers fixed with formalin are not suitable for surgical training because of their associated health hazards and overhardening. Recently, we established a formalin-free soft preservation method for human cadavers using N-vinyl-2-pyrrolidone. Since 2012, 61 cadavers have been embalmed with pyrrolidone in our institution. Tissues of pyrrolidone-embalmed cadavers are soft and pliable, and their bodies can be preserved for as long as 37 months without any signs of corruption. In this review, we introduce our recent attempts to apply pyrrolidone-embalmed cadavers in surgical and medical procedure training, including endotracheal intubation, motion physiology of the vocal folds, laparoscopic surgery, endoscopic skull base surgery, and development of novel medical devices. Future research perspectives on pyrrolidone embalming are discussed.

2021 Update on airway management from the Anaesthesia Continuing Education Airway Management Special Interest Group

Airway Management is the key for anaesthetists dealing with patients undergoing diagnostic procedures and surgical interventions. The present coronavirus pandemic underpins even more how important safe airway management is. It also highlights the need to apply stringent precautions to avoid infection and ongoing transmission to patients, anaesthetists and other healthcare workers (HCWs). In light of this extraordinary global situation the aim of this article is to update the reader on the varied aspects of the ever-changing tasks anaesthetists are involved in and highlight the equipment, devices and techniques that have evolved in response to changing technology and unique patient and surgical requirements.

Enhanced Experiential Learning in Airway Management: Surgical Modification of Cadavers

INTRODUCTION

Failure of airway management remains a significant source of morbidity and mortality. Advanced airway management has been addressed effectively by simulation-based training. However, simulation of difficult airways in manikins is limited by the pre-set conditions provided by the manufacturer. Life-like conditions in the form of the softness of the tissue and true anatomy as seen in cadaver models are needed to create simulated models with a closer resemblance to real patients. The goal of this study was to determine the feasibility of simulating difficult airway from submandibular abscess in cadaver models by surgical modification of the cadaver heads for use in enhanced experiential learning of the management of difficult airways.

METHODS

The cadaver heads were modified surgically to simulate a submandibular abscess. The models were used in an airway course where participants provided feedback on the realistic nature of the model and its benefits for difficult airway training. The ease of tracheal intubation of the models with the assistance of video laryngoscopy was assessed.

RESULTS

The modified cadavers were acceptable in simulating difficult airway as demonstrated by the feedback from the participants. All participants (100% [95% confidence interval = 89.1%-100%]) found the models to be realistic and beneficial for difficult airway training. A good proportion (56.3%) felt that the intubation technique was made easier with the video laryngoscopy.

CONCLUSIONS

Cadavers can be modified to simulate pathologies associated with difficult airways. These models can be used to enhance experiential learning and the management of difficult airways.

Experiential learning in simulated parapharyngeal abscess in breathing cadavers

Purpose

Education in airway management is a fundamental component of anesthesiology training programs. There has been a shift towards the use of simulation models of higher fidelity for education in airway management. The goal of this study was to create a novel cadaveric model of a simulated parapharyngeal abscess with features of a difficult airway such as distorted anatomy and narrow airway passages presenting as stridor. The model was further assessed for its suitability for enhanced experiential learning in the management of difficult airways.

Methods

Cadaver heads were modified surgically to simulate parapharyngeal abscess. Airtight torso of the cadaver was connected to an Oxylog ventilator to simulate respiratory movements—the opening and closing of air channels with breaths in a patient with parapharyngeal abscess. Advanced airway workshop facilitators conducted directed one-to-one learning, and provided feedback to participants. A paper-based feedback was obtained from 72 participants on their confidence level, and the realism, attractiveness, beneficial, and difficulty levels of the simulated cadaveric models.

Results

The modified cadavers were reliable in simulating difficult airways. The majority of participants (91%) reported an increase in confidence level for management of the difficult airway after the experience with the modified cadavers and found the models realistic (93%), attractive (92%), beneficial (93%), and difficult (85%).

Conclusions

Surgical modifications of cadavers to simulate difficult airways such as parapharyngeal abscess with edema and stridor can be incorporated into advanced airway management courses to enhance experiential learning in airway management by awake fibreoptic intubation, and promote patient safety.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00540-021-02904-0.

Suitability and realism of the novel Fix for Life cadaver model for videolaryngoscopy and fibreoptic tracheoscopy in airway management training

Background

Videolaryngoscopy is increasingly advocated as the standard intubation technique, while fibreoptic intubation is broadly regarded as the ‘gold standard’ for difficult airways. Traditionally, the training of these techniques is on patients, though manikins, simulators and cadavers are also used, with their respective limitations. In this study, we investigated whether the novel ‘Fix for Life’ (F4L) cadaver model is a suitable and realistic model for the teaching of these two intubation techniques to novices in airway management.

Methods

Forty consultant anaesthetists and senior trainees were instructed to perform tracheal intubation with videolaryngoscopy and fibreoptic tracheoscopy in four F4L cadaver models. The primary outcome measure was the verbal rating scores (scale 1–10, higher scores indicate a better rating) for suitability and for realism of the F4L cadavers as training model for these techniques. Secondary outcomes included success rates of the procedures and the time to successful completion of the procedures.

Results

The mean verbal rating scores for suitability and realism for videolaryngoscopy was 8.3 (95% CI, 7.9–8.6) and 7.2 (95% CI, 6.7–7.6), respectively. For fibreoptic tracheoscopy, suitability was 8.2 (95% CI, 7.9–8.5) and realism 7.5 (95% CI, 7.1–7.8). In videolaryngoscopy, 100% of the procedures were successful. The mean (SD) time until successful tracheal intubation was 34.8 (30.9) s. For fibreoptic tracheoscopy, the success rate was 96.3%, with a mean time of 89.4 (80.1) s.

Conclusions

We conclude that the F4L cadaver model is a suitable and realistic model to train and teach tracheal intubation with videolaryngoscopy and fibreoptic tracheoscopy to novices in airway management training.

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.

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.

Comparison of a Novel Cadaver Model (Fix for Life) With the Formalin-Fixed Cadaver and Manikin Model for Suitability and Realism in Airway Management Training

BACKGROUND

Manikins are widely used in airway management training; however, simulation of realism and interpatient variability remains a challenge. We investigated whether cadavers embalmed with the novel Fix for Life (F4L) embalmment method are a suitable and realistic model for teaching 3 basic airway skills: facemask ventilation, tracheal intubation, and laryngeal mask insertion compared to a manikin (SimMan 3G) and formalin-fixed cadavers.

METHODS

Thirty anesthesiologists and experienced residents ("operators") were instructed to perform the 3 airway techniques in 10 F4L, 10 formalin-fixed cadavers, and 1 manikin. The order of the model type was randomized per operator. Primary outcomes were the operators' ranking of each model type as a teaching model (total rank), ranking of the model types per technique, and an operator's average verbal rating score for suitability and realism of learning the technique on the model. Secondary outcomes were the percentages of successfully performed procedures per technique and per model (success rates in completing the respective airway maneuvers). For each of the airway techniques, the Friedman analysis of variance was used to compare the 3 models on mean operator ranking and mean verbal rating scores.

RESULTS

Twenty-seven of 30 operators (90%) performed all airway techniques on all of the available models, whereas 3 operators performed the majority but not all of the airway maneuvers on all models for logistical reasons. The total number of attempts for each technique was 30 on the manikin, 292 in the F4L, and 282 on the formalin-fixed cadavers. The operators' median total ranking of each model type as a teaching model was 1 for F4L, 2 for the manikin and, 3 for the formalin-fixed cadavers (P < .001). F4L was considered the best model for mask ventilation (P = .029) and had a higher mean verbal rating score for realism in laryngeal mask airway insertion (P = .043). The F4L and manikin did not differ significantly in other scores for suitability and realism. The formalin-fixed cadaver was ranked last and received lowest scores in all procedures (all P < .001). Success rates of the procedures were highest in the manikin.

CONCLUSIONS

F4L cadavers were ranked highest for mask ventilation and were considered the most realistic model for training laryngeal mask insertion. Formalin-fixed cadavers are inappropriate for airway management training.

Training Effectiveness of a Wide Area Virtual Environment in Medical Simulation

INTRODUCTION

The success of war fighters and medical personnel handling traumatic injuries largely depends on the quality of training they receive before deployment. The purpose of this study was to gauge the utility of a Wide Area Virtual Environment (WAVE) as a training adjunct by comparing and evaluating student performance, measuring sense of realism, and assessing the impact on student satisfaction with their training exposure in an immersive versus a field environment.

METHODS

This comparative prospective cohort study examined the utility of a three-screen WAVE where subjects were immersed in the training environment with medical simulators. Standard field training commenced for the control group subjects. Medical skills, time to completion, and Team Strategies and Tools to Enhance Performance and Patient Safety objective metrics were assessed for each team (n = 94). In addition, self-efficacy questionnaires were collected for each subject (N = 470).

RESULTS

Medical teams received poorer overall team scores (F1,186 = 0.756, P = 0.001), took longer to complete the scenario (F1,186 = 25.15, P = 0.001), and scored lower on The National Registry of Emergency Medical Technicians trauma assessment checklist (F1,186 = 1.13, P = 0.000) in the WAVE versus the field environment. Critical thinking and realism factors within the self-efficacy questionnaires scored higher in the WAVE versus the field [(F1,466 = 8.04, P = 0.005), (F1,465 = 18.57, P = 0.000), and (F1,466 = 53.24, P = 0.000), respectively].

CONCLUSIONS

Environmental and emotional stressors may negatively affect critical thinking and clinical skill performance of medical teams. However, by introducing more advanced simulation trainings with added stressors, students may be able to adapt and overcome barriers to performance found in high-stress environments.

Hands-on Training Methods for Vocal Fold Injection Education

Objectives:

Vocal fold injection (VFI) in the office setting and in the operating room is becoming increasingly popular. Most training programs fail to educate residents in performing these injections. In this report, we describe novel and effective teaching tools that provide real-life simulation of VFI for the education of residents and otolaryngologists in practice.

Methods:

Equipment was developed to allow the use of excised fresh cadaver larynges to simulate peroral VFI in a life-sized model of the human head and neck. A separate setup was also developed for use of a laryngoscope holder and cadaver larynges to simulate microlaryngoscopy VFI. Each of these VFI training setups allows the student to perform and practice VFI in a simulated setting with physical and anatomic constraints and laryngeal anatomy similar to those of real-life VFI. The use of fresh cadaver larynges allows the user to have a realistic feel of actual injection. A visual analog scale was used to measure the participants' comfort levels with the peroral and microlaryngoscopic injection techniques before and after the workshop.

Results:

Pre-workshop and post-workshop surveys were collected from 22 of the VFI course participants. The mean comfort levels for VFI prior to the workshop were 22 for peroral VFI and 69 for microlaryngoscopy VFI (0 = not comfortable at all and 100 = very comfortable). The post-workshop comfort levels were 52 for peroral VFI and 85 for microlaryngoscopy VFI. The differences in the pre- and post-workshop comfort level scores for each VFI technique were significant (microlaryngoscopy, p = .001; peroral, p <0001).

Conclusions:

The use of VFI simulations appears to improve surgeon comfort level with injection techniques. The described training simulations may be useful for allowing residents and practicing otolaryngologists to learn VFI before attempting these techniques on actual patients.

[Proposed difficult airway teaching methodology. Presentation of an interactive fresh frozen cadaver model]

BACKGROUND AND OBJECTIVE

The aim of this paper is to present a methodology based on the use of fresh-frozen cadavers for training in the management of the airway, and to evaluate the degree of satisfaction among learning physicians.

MATERIAL AND METHODS

About 6 fresh-frozen cadavers and 14 workstations were prepared where participants were trained in the different skills needed for airway management. The details of preparation of the cadavers are described. The level of satisfaction of the participant was determined using a Likert rating scale of 5 points, at each of the 14 stations, as well as the overall assessment and clinical usefulness of the course.

RESULTS

The mean overall evaluation of the course and its usefulness was 4.75 and 4.9, out of 5, respectively. All parts of the course were rated above 4 out of 5. The high level of satisfaction of the course remained homogeneous in the 2 editions analysed. The overall satisfaction of the course was not finally and uniquely determined by any of its particular parts.

CONCLUSION

The fresh cadaver model for training physicians in techniques of airway management is a proposal satisfactory to the participant, and with a realism that approaches the live patient.

Learning endotracheal intubation using a novel videolaryngoscope improves intubation skills of medical students

INTRODUCTION

Teaching endotracheal intubation to medical students is a task provided by many academic anesthesia departments. We tested the hypothesis that teaching with a novel videolaryngoscope improves students' intubation skills.

METHODS

We prospectively assessed in medical students (2nd clinical year) intubation skills acquired by intubation attempts in adult anesthetized patients during a 60-hour clinical course using, in a randomized fashion, either a conventional Macintosh blade laryngoscope or a videolaryngoscope (C-MAC®). The latter permits direct laryngoscopy with a Macintosh blade and provides a color image on a video screen. Skills were measured before and after the course in a standardized fashion (METI Emergency Care Simulator) using a conventional laryngoscope. All 1-semester medical students (n = 93) were enrolled.

RESULTS

The students' performance did not significantly differ between groups before the course. After the course, students trained with the videolaryngoscope had an intubation success rate on a manikin 19% higher (95% CI 1.1%-35.3%; P < 0.001) and intubated 11 seconds faster (95% CI 4-18) when compared with those trained using a conventional laryngoscope. The incidence of "difficult (manikin) laryngoscopy" was less frequent in the group trained with the videolaryngoscope (8% vs 34%; P = 0.005).

CONCLUSION

Education using a video system mounted into a traditional Macintosh blade improves intubation skills in medical students.

Simulation-based medical education is no better than problem-based discussions and induces misjudgment in self-assessment

Simulation-based teaching (SBT) is increasingly used in medical education. As an alternative to other teaching methods there is a lack of evidence concerning its efficacy. The aim of this study was to evaluate the potency of SBT in anesthesia in comparison to problem-based discussion (PBD) with students in a randomized controlled setting. Thirty-three fourth-year medical students attending a curricular anesthesiology course were randomly allocated to either a session of SBT or a session of PBD on an emergency induction method. Ten days later all students underwent examination in a simulator. The performance of each student was evaluated by weighted tasks, established according to a modified Delphi process. Confidence and a multiple-choice questionnaire were additionally performed pre- and post-intervention. A total of 32 students completed the study. Participants in the SBT group presented with significantly higher self-assessment scores after the intervention than students in the PBD group. However, students in the SBT group achieved only slightly and statistically insignificantly higher scores in the theoretical and simulator examination (p > 0.05) with only a moderate effect size of d = 0.52. The current study demonstrates that both PBD and SBT lead to comparable short-term outcomes in theoretical knowledge and clinical skills. However, undesirably, SBT students overrated their anticipated clinical abilities and knowledge improvement.

Developing technical expertise in emergency medicine--the role of simulation in procedural skill acquisition

Developing technical expertise in medical procedures is an integral component of emergency medicine (EM) practice and training. This article is the work of an expert panel composed of members from the Society for Academic Emergency Medicine (SAEM) Interest Group, the SAEM Technology in Medical Education Committee, and opinions derived from the May 2008 Academic Emergency Medicine Consensus Conference, "The Science of Simulation in Healthcare." The writing group reviewed the simulation literature on procedures germane to EM training, virtual reality training, and instructional learning theory as it pertains to skill acquisition and procedural skills decay. The authors discuss the role of simulation in teaching technical expertise, identify training conditions that lead to effective learning, and provide recommendations for future foci of research.

Perception of training needs and opportunities in advanced airway skills

BACKGROUND AND OBJECTIVE

We surveyed delegates at the Group of Anaesthetists in Training (UK) meeting to investigate evidence of a training-gap (number of fibreoptic intubations believed to bestow competence vs. number actually performed).

METHODS

Questionnaires were distributed to and collected from delegates in person. Questions covered six areas, including experience of fibreoptic intubation and cricothyrotomy, fibreoptic intubation as a specialist skill and ethical issues.

RESULTS

We received 221 replies (76%). All trainees believed competence to be achievable with 10 intubations (interquartile range (IQR) 10-20); the median number performed was 2 (IQR 0-4). This was statistically significant for the groups' senior house officers, 1st and 2nd year registrars and 3rd and 4th year registrars; P < 0.0001. Many final year trainees (12/20, 60%) also failed to achieve their competency target. Few trainees had seen or performed any cricothyrotomies (medians 0, IQRs 0-1 and 0-0). Most (195/208, 94%) believed that fibreoptic intubation was a core skill and 199/212 (94%) believed that all should be competent by completion of training. Ten percent (n = 208) felt it unethical to perform an awake training intubation with full consent and 10% believed it acceptable without explanation. Most (82.7%) would fibreoptically intubate an asleep patient (requiring intubation) without consent.

CONCLUSION

Trainees reported a gap between their perception of competence and achievement in awake fibreoptic intubation. Simple and complex simulations and structured training programmes may help. Anaesthetists must address the ethics of clinical training in advanced airway management.