You are on page 1of 3

I would have everie man write what he knowes and no more.

MONTAIGNE

BRITISH JOURNAL OF ANAESTHESIA


VOLUME 81, No. 3

SEPTEMBER 1998
EDITORIAL I
Education and training in airway management

Airway management is the scaffolding upon which


the whole practice of anaesthesia is built.
Consequently, education in airway skills must
occupy a central place in anaesthetic training, since it
is within the realms of respiratory management that
the penalties for misadventure are greatest. Adverse
respiratory events accounted for more than onethird of 2046 US closed malpractice claims1 and the
commonest causes were inadequate ventilation,
oesophageal intubation, difficult intubation and
airway obstruction.2 Eighty-five percent of these respiratory events resulted in brain damage or death,
72% were judged by the assessors to have been
preventable and 75% involved substandard care.
As concurrent failure of tracheal intubation and
mask ventilation may ultimately result in death or
brain damage, these two basic techniques are the most
important that an anaesthetist learns. Unfortunately,
there are three factors that have combined to reduce
trainees exposure to tracheal intubation and mask
ventilation in the past few years: reduction in time
spent in the operating theatre; introduction of other
means of managing the airway; and a greater use of
regional anaesthetic techniques. In addition, there is
a perception among UK trainees that the basic techniques are easy and not worthy of the meticulous,
disciplined approach they deserve. This observation
has sometimes been made by overseas visitors.3
Until recently, anaesthetic training was relatively
unstructured, so that skills and knowledge were
acquired haphazardly. However, this deficiency was
partially minimized by the length and breadth of the
apprenticeship. Recent condensation of specialist
training in the UK4 and the decreased time now
spent in the operating theatre have made it imperative that anaesthetic training as a whole should
become more organized. This applies particularly to
airway management. Instead of learning the use of a
simple face mask and tracheal tube, todays trainee is
faced with an ever increasing number of airway
devices and techniques. Not only must the trainee be
taught how to use new equipment, but when and
when not to use it. Airway safety may be compromised easily by performing a good technique badly,
or by using it in inappropriate circumstances.
Even before publication of the Calman Report,4
several departments had seen the importance of specific airway training, but efforts were concentrated
mainly on providing short-term courses on special
techniques for the difficult airway. Several have
pioneered national workshops, while a few provide
specific airway rotations within the conventional
training schedule.5 6 These are considered excellent
by anaesthetists fortunate enough to attend, but are
expensive, time consuming and relatively exclusive.
There is also a danger that substantial investment in

the provision of concentrated experience for the privileged few may result in dilution of training opportunities for the majority. Difficult techniques, however,
cannot be mastered during short workshops, and
skills need practice and repeated reinforcement.6
Short, concentrated courses should be considered
supplementary to in-house teaching. Expertise in airway management can only be acquired gradually,
over a long period of clinical experience, not in a few
days.
At present, relatively few hospitals attempt to coordinate the training of airway management. A recent
survey of tutors of the Royal College of Anaesthetists
noted that only 37% of UK departments offered formal airway training and few actually provided details
of the modules.7 Similar deficiencies in postgraduate
programmes have been shown in the USA.8
How can teaching in airway management be
improved? The Royal College of Anaesthetists
provides an extensive syllabus of subjects for the
FRCA examinations9 and details of modules, training objectives and assessments.10 Each specialty
module contains some elements pertinent to the airway, but these are never specifically drawn together
to provide a comprehensive airway syllabus.
There is little guidance for consultants as to how to
teach modern airway management and little research
undertaken into educational methods that are directly
relevant to postgraduate training in anaesthesia. The
present situation, in which consultants are required
to organize a 24-h clinical service in anaesthesia and
at the same time provide individualized teaching for
groups of itinerant Calman trainees, must be unique.
In what other profession would untrained teachers,
with little time and fewer facilities, be expected to
provide comprehensive education for trainees with
such widely different levels of experience?
Emphasis has been placed on the future of electronic means of teaching. Some excellent videos have
been made, but the full potential of interactive CD
ROMs has still to be realized. Teleconferencing is not
the answer for the medical postgraduate. Even in
undergraduate education, experts in the field are
agreed that electronic networks have yet to achieve
their proper role11 and it is unlikely that they can ever
replace the experience of diagnosing and treating a
patient.12 Theatre-type simulators13 can only play a
minor role in airway training, as they are intended
primarily to prepare the anaesthetist to manage a crisis. In teaching airway management, the emphasis
should be on how to avoid the crisis situation. Airway
training should be primarily for peacetime, not for
war.
Unfortunately, there can be no substitute for working at the coal-face. Those who have forged the new
postgraduate education strategy have failed to recog-

306
nize the special needs of trainees in the artisan specialties of surgery and anaesthesia. Facts and theory
can be learned from books and in the classroom. They
can be reiterated when required for examination, lecture and interview purposes. Individual manual skills
can be taught in isolation. However, it is only in the
work place that the trainee can learn to combine
these, together with the indefinable philosophies of
judgment, experience, humanity and ethics, into the
total process of giving an anaesthetic.
The most important places for anaesthetic training
are the ward, the operating theatre and the intensive
care unit, not the classroom and the library. The
influence of clinical teachers as role models for students cannot be underestimated.14 Good anaesthesia
teachers combine enthusiasm, willingness to teach
and an inquiry approach.15 The worth of such clinicians must be recognized formally and time and
facilities made available, to avoid frustration and
burnout.16 Many hospital consultants involved in the
emergency specialties of anaesthesia and surgery are
now retiring early and the profession can ill afford
this loss of experienced teachers.
These are the problems. What are the solutions?
The initial steps require commitment, organization
and money. The Royal College, members of the profession, and trainees must acknowledge that: modern
airway management requires special attention; the
majority of training must be done in the workplace,
not in special centres; and it consumes resources.
Funding will be required from Postgraduate Deans,
NHS managers and purchasers, so that each anaesthetic department involved in training can equip an
airway training room.
The contents of a syllabus of both basic and
advanced airway management must be agreed.
Airway management should be interpreted in its
widest possible sense. It should encompass the theory and practice of a variety of respiratory-related
procedures and associated equipment. It will include
the basic skills of airway assessment, mask ventilation, tracheal intubation and airway decision making,
in addition to the more advanced techniques of fibreoptic intubation and percutaneous tracheostomy.
One or two consultants with the appropriate expertise should be identified as coordinator/s. However,
every consultant has something to offer and the
teaching load should be spread widely.
On arrival in a new department, each trainee,
whatever grade, should be given the syllabus and the
aims explained. The syllabus can be used by the
trainee as a checklist and by the trainer as a prompt
for teaching or inquiry during a theatre session.
However, it should be made clear that the ultimate
responsibility rests with the trainee to maximize the
experience obtained during each relevant part of
training. For example, during the ENT module,
discussion of upper airway problems, endoscopies,
laser techniques, special tubes, Venturi systems, etc.,
would take place.
The coordinator should document the initial
encounter, the trainees particular requirements and
attendance at group training sessions. A register will
help to emphasize the more formal nature of the new
arrangements and allow the coordinator to assess a
trainees progress from time to time. An intended
function of the log book was to enable trainees to

British Journal of Anaesthesia


identify their own deficiencies. Strang showed that
they were rarely used for this purpose.17 Trainees
require prompting, but recognition of their own
responsibilities within the new system is fundamental. Unfortunately, the reduction in hours of work has
fostered a minimalist approach by some trainees.
However, procedures, problems and patients do not
necessarily present at convenient times and it must
be accepted that flexibility and initiative are essential
components of professional training.
A training room must be equipped within the
anaesthetic department. Airway management training is entirely different from resuscitation training
and must be kept separate. However, as with CPR
training, the use of manikins is now essential for several reasons. The patient must be protected from the
total novice. Some of the new airway procedures are
relatively complex, therefore the trainee must be
given the opportunity to practise manoeuvres in an
unstressful way. Disposable items are relatively
expensive, but experience and use of the components
can be economically gained by reusing them on a
manikin. The quality of manikins improves steadily,
as does their specific teaching value. Scopin II
Bronchoboy (Adam, Rouilly Limited, Sittingbourne,
Kent) is a dedicated bronchoscopic trainer with
detachable lungs and bronchial tree. It can be used
for manipulation of the fibreoptic bronchoscope
through the larynx and the bronchial tree and for
learning bronchoscopic anatomy, with and without
the chest wall in place. A cricothyrotomy simulator
(VBM Medizintechnik GmbH, Freelance Surgical
Promotions, Bristol) can be used for practising
cricoid pressure technique, cricothyrotomy, setting
up a Venturi device and simulating retrograde intubation techniques. Audiovisual facilities should be
available within the department and a library of
videos and CD ROMs can be built up gradually.
After the initial purchases, a modest maintenance
budget is required to provide new items, replace
worn ones and renew disposable parts.
The department should agree on a simple scheme
for the management of the unexpected difficult
intubation/airway. This could be based on the algorithm approved by the American Society of
Anesthesiologists.18 However, it is important that the
complex-looking posters that adorn many anaesthetic room walls should be simplified into a number
of logical steps. The basic manoeuvres that optimize
initial attempts at intubation and mask ventilation
must be emphasized.19 After such a plan has been
agreed, a trolley should be equipped to contain only
those items specified in the algorithm. Each item on
the trolley should be duplicated in the training room,
so that trainees have the opportunity to practise their
use on a manikin. Every new intake of trainees must
attend a training session and regularly examine the
trolley.
Before allowing a trainee to undertake an
advanced technique such as fibreoptic intubation or
percutaneous tracheostomy on a patient, considerable preparation should have taken place. Complex
skills are best learned gradually, by dividing the complete process into several simpler tasks.20 For fibreoptic intubation, there are numerous opportunities
to learn outside the operating theatre. Attendance at
diagnostic bronchoscopy lists21 and ENT outpatients22

Editorial I
allows trainees to obtain useful tips from other
specialists, while practice on the manikin improves
manual skills.23 Fibreoptic techniques can be
acquired by graduated training.20 Only those trainees
who have already demonstrated their mastery of the
basic steps should be given the opportunity to perform the technique under supervision. Percutaneous
tracheostomy presents similar teaching challenges
and the report in this issue of the journal of a method
of training, using an animal model and a video
camera, demonstrates the ingenuity of some trainers
in devising new ways of teaching more complex techniques.24
The length of time to complete specialist training
has been reduced, but as yet there is no evidence that
anaesthetists can acquire sufficiently wide clinical
experience and education within this limited time
scale.
One implication of the new Calman training system is a greater dependence on teaching by ordinary
practising clinicians,25 most of whom are untrained
for this role. These major changes have been made
with little or no provision for support at this level, no
formally recognized time for teaching and no investment in modern teaching facilities.
While airway management is only a single aspect of
anaesthetic training, it is probably the one for which
the availability of good teachers and training equipment are most essential. Anaesthetic departments
must have trainers with dedicated time in which to
teach airway management and a budget with which
to equip an airway training room. The cost of these
initial steps would be small compared with the price
of a single failure of airway management that resulted
in brain damage or death. Resuscitation training is
already well established within hospitals. There is
even more reason to provide similar facilities for airway management training.
R. A. MASON
Department of Anaesthesia
Swansea NHS Trust
Singleton Hospital
Swansea SA2 8QA

References
1. Cheney FW, Posner KL, Caplan RA. Adverse respiratory
events infrequently leading to malpractice suits. A closed
claims analysis. Anesthesiology 1991; 75: 932939.
2. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse
respiratory events in anesthesia: a closed claims project.
Anesthesiology 1990; 72: 828833.
3. Asai T. A Japanese in Cardiff: some thoughts on Western science. In: Appadurai IR, Horton JN, eds. Essays on the First

307

4.
5.
6.
7.

8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

19.

20.
21.
22.
23.
24.
25.

Fifty Years 19471997. Cardiff: University of Wales College of


Medicine, 1997.
Hospital doctors: training for the future. The Report of the
Working Group on Specialist Medical Training (Calman
Report) 1993.
Cooper SD, Benumof JL. Teaching management of the airway: the UCSD airway rotation. In: Benumof JL, ed. Airway
Management. Principles and Practice. St Louis: Mosby, 1996.
Koppel JN, Reed AP. Are postgraduate fiberoptic-guided intubation workshops accomplishing their goals? Anesthesia and
Analgesia 1994; 78: S216.
Turley A, Latto IP. Questionnaire on airway management circulated to tutors of the Royal College of Anaesthetists.
Proceedings of Difficult Airway Society Meeting, March
1997.
Koppel JN, Reed AP. Formal instruction in difficult airway
management. A survey of anesthesiology residency programs.
Anesthesiology 1995; 83: 13431346.
Primary and Final Examinations for the FRCA Syllabus.
London: Royal College of Anaesthetists, 1997.
Specialist Training in Anaesthesia, Supervision and Assessment.
London: Royal College of Anaesthetists, 1994.
Tangalos EG, McGee R, Bigbee AW. Use of the new media for
medical education. Journal of Telemedicine and Telecare 1997; 3:
4047.
Jaffe CC, Lynch PJ. Educational challenges. Radiologic Clinics
of North America 1996; 34: 629646.
Spence AA. The expanding role of simulators in risk management. British Journal of Anaesthesia 1997; 78: 633634.
Wright S, Wong A, Newill C. The impact of role models on
medical students. Journal of General Internal Medicine 1997;
12: 5356.
Cleave-Hogg D, Benedict C. Characteristics of good anaesthesia teachers. Canadian Journal of Anaesthesia 1997; 44:
587591.
Shysh AJ, Eagle CJ. The characteristics of excellent clinical
teachers. Canadian Journal of Anaesthesia 1997; 44: 577578.
Strang TI. Anaesthetic log books. How are they being used?
Anaesthesia 1993; 48: 6974.
Practice guidelines for management of the difficult airway.
Report by the American Society of Anesthesiologists task
force for management of the difficult airway. Anesthesiology
1993; 78: 597602.
Benumof JL. The American Society of Anesthesiologists
management of the difficult airway algorithm and explanation-analysis of the algorithm. In: Benumof JL, ed. Airway
Management. Principles and Practice. St Louis: Mosby, 1996.
Ovassapian A. Learning fiberoptics. In: Ovassapian A, ed.
Fiberoptic Endoscopy and the Difficult Airway. Philadelphia:
Lippincott-Raven, 1996.
Mason RA. Learning fibreoptic intubation; fundamental
problems. Anaesthesia 1992; 67: 729731.
Burke LP, Osborn NA, Smith JE, Reid AP. Learning fibreoptic skills in ear, nose and throat clinics. Anaesthesia 1996;
51: 8183.
Ovassapian A, Yelich SJ, Dykes MHM, Golmon ME. Learning
fibreoptic intubation; use of simulators v traditional teaching.
British Journal of Anaesthesia 1988; 61: 217220
Gardiner Q, White PS, Carson D, Shearer A, Frizelle F,
Dunkley P. Technique training: endoscopic percutaneous tracheostomy. British Journal of Anaesthesia 1998; 81: 400402.
Burnstein RM, Jeevaratnam RD, Jones JG. The need for basic
sciences in the understanding and practice of anaesthesia.
Anaesthesia 1997; 52: 935944.