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Simulation Training for Advanced Airway

Management for Anesthesia and Other
Healthcare Providers: A Systematic Review

Karen E. Lucisano, CRNA, MSN
Laura A. Talbot, RN, EdD, PhD, GCNS-BC

We studied the current literature on human patient tion evaluation for a variety of medical, nursing, and
simulation for preparing anesthesia and other health- allied health providers and students. Only 6 studies
care providers for advanced airway management. A addressed the use of simulation as an educational or
systematic review was conducted of articles published evaluation tool to enhance training of anesthesia pro-
between 1990 and 2009 on advanced airway manage- viders in difficult airway management. Those studies
ment for patients undergoing anesthesia and patients included analyses of different types of training and
who are not. The search used 4 electronic databases: the perceived value of simulated training, and evalu-
Cumulative Index to Nursing & Allied Health Litera- ations of equipment. Few studies have analyzed the
ture, MEDLINE, PsycINFO, and Web of Science. effects of this modality on trainer skills and patient
We included 34 articles in the analysis; 15 were safety. There is a clear need for well-designed studies
experimental or quasi-experimental designs, 8 de- to examine these effects.
scriptive studies and reports, and 11 analyses of
equipment or technique evaluations using simulation. Keywords: Difficult airway management, general anes-
The majority of the studies included simulation educa- thesia, patient safety, simulation training.

nability to secure the airway during the induction practitioners require recurring practice to hone their
phase of a general anesthetic has the potential for skills for rapid resolution. To avoid the risk of harming
substantial morbidity and mortality. Comorbid con- patients, a structured simulation training protocol may
ditions likely to pose a substantial risk of hypoxic be used to prepare anesthesia providers for difficult
injury during induction include pregnancy, multiple airway management.
trauma, and obesity. Obesity is of particular concern Human patient simulation offers the ability to provide
because it increases the risk of difficult airway in addition anesthesia students and providers a structured and stan-
to reducing the functional residual capacity and increas- dardized experience and to demonstrate proper manage-
ing metabolism, ultimately leading to a reduction in the ment of uncommon but high-risk events with no danger
time a person can tolerate hypoxia. In the United States, of injury to a patient. This article reviews the literature
more than 30% of adults and 15% of children are obese.1 on human patient simulation for training anesthesia and
This high prevalence of obesity and the need to act rap- other healthcare providers for advanced airway assess-
idly and efficiently to ensure an uninterrupted supply ment and management.
of oxygen have led to the need to ensure that anesthesia
providers are competent in the knowledge and technical Search Strategy
skills of difficult airway management. We used 4 electronic databases: Cumulative Index to
In an effort to improve outcomes, the American Nursing & Allied Health Literature (CINAHL; January
Society of Anesthesiologists has adopted an algorithm 1, 1995 to September 25, 2009), MEDLINE (January 1,
that can be followed when an anesthetist is unable to 1990 to September 25, 2009), PsycINFO (January 1, 2000
establish an airway using traditional methods. However, to September 25, 2009), and Web of Science (January 1,
despite these guidelines, malpractice claims related to 1990 to September 25, 2009). For the CINAHL search,
failure to secure the airway persist.2 we used the following search terms: “airway manage-
Typically, novice practitioners learn airway manage- ment” and “simulation.” This search obtained 16 “hits.”
ment on real patients using a bedside apprentice model. We searched MEDLINE using 2 indexes: the PubMed
Exposure to real patients is essential, but substandard index, using the search terms “airway management” and
performance can put patients at risk, especially when “simulation” and “anesthesia,” which generated 44 hits,
traditional airway management is ineffective and an and by the CSA Illumina index, using the search terms
alternative approach is urgently needed. Even seasoned “airway management” and “simulation,” which generated AANA Journal  February 2012  Vol. 80, No. 1 25

Study purposes included the following: were duplicates. over time 3. 26 AANA Journal  February 2012  Vol. It is interesting that when we added “anesthesia” training process for anesthesia or other healthcare pro- to the search term in this index. The study samples varied widely. 34 were considered further. “airway management” and “simulation” and produced 4 During this phase. The criteria were as follows: (1) were included in this review (see Figure).13-17 (Table 1). Cumulative Index to Nursing & Allied Health Literature. Graphic of Search Abbreviations: CINAHL. pediatric residents and fellows.7 re- process for anesthesia or other healthcare providers. No.4 medical and dental comes.11 (3) clearly stated study objectives with measured out. Samples Results ranged from 12 to 120 subjects.26-36 In accordance the review to the methods section of each article from with the predetermined inclusion criteria. we 15 were randomized controlled trials. (2) inclusion • Study Samples. 1 www. and 1 was not available in English. management” and “simulation” and received 126 hits. The 1. We engaged in detailed discussions to resolve any residents. There were 6 studies that included anesthesia residents and/or anesthesia providers5. Of the 87 studies. and clearly stated study objectives with measured returned fell to 6. 41 • Study Purpose. the number of articles viders. and spiratory therapists. A comparison of the effects of simulation training clusion criteria: use of an experimental or quasi-experi. and other students.12 inclusion in the review based on the predetermined in. experimental or quasi-experimental An analysis of the effects of simulation on single or 87 nonduplicated articles were screened for possible multiple airway task completion7. CSA. n = 44 n = 33 Science n=4 n = 16 AM & S & A AM. A total of 129 studies were considered for review. 15 articles3-17 the selected databases. of a simulated advanced airway management training They included physician and paramedic teams. An analysis of the effects of different types of simu- and and Total articles = 129 MEDLINE via MEDLINE via CSA Web of PshycINFO CINAHL PubMed.18-25 and the remaining 11 studies used simu- 32 hits (Figure). 2. lation as a tool to evaluate equipment or techniques or We independently applied the eligibility criteria for a specific simulator’s level of fidelity. nursing students. Finally. we searched Web of Science using “airway viewed in a more detailed evaluation.12.8 disagreements on articles for study inclusion. PsycINFO was searched with the terms outcomes. the full article was acquired and re- hits. CSA Illumina.aspx .aana. S AM. S n = 32 AM. a simulated advanced airway management 3.5.6 flight nurses and paramedics.3-17 8 were descrip- then refined the subject area to “anesthesia” and received tive studies. Of the 34 studies.10. n = 42 n = 11 Science n=4 n = 14 n = 16 Abstract screen/review Delete 1 non- English article 34 Articles further analyzed 15 8 11 Equipment or Randomized controlled Descriptive studies technique evaluations trails 15 Studies included in review Figure.9.33 hits. S Total nonduplicated articles = 87 MEDLINE via MEDLINE via CSA Web of PshycINFO CINAHL PubMed.16 mental design. S AM.

and time used to kin simulation can be effective methods to pation dents. Observational study Intubation of an adult Time to intubation Novices and experts improved time to Steinfeldt. in cadaver group. intubation. Performance defi. graded at TLX scores (perceived ceived workload decreased by 30% from residents’ adverse experimental group. stan. experimental and variable priority dard didactic and Exam I-III. experi- 2008 principles of part thesia residents. Wash. measured for an adult intubation the same in novice training and teach fiberoptic ulator (n = 4). nov. workload) ment and respira.encounters observational study ciencies in airway ciencies in 11 cases cies of airway man. 48 trauma patient Nonexperimental. and medical ington) presentation study the slideshow and teach a complex motor skill students not experi. Redmond. in-training examination unanticipated difficult weighted task scores. time to at first attempt to intubate. experts.001).the beginning and end physical and cognitive baseline in both groups airway manage. performance evaluated by 2 indepen- VPT training (n = 11) dent. prepared by experts. group showed greater increase in correct training (VPT) would simulation-based in 7 simulation-based tions. composite NASA. mental group able to complete 9% more task training (PTT) score. structured self-learning programs and mani- active expert partici. other types of reports missed the majority of deficien- Vol.15 that a virtual reality novice nontraining using FOI intubation before and following a intubation VR FOI. expert groups but longer in novice nontrain- intubation (FOI) ice training group. standard and didac-of 1 year of training. total time to successfully intubated in ≤ 5 min. No. Compared with video analysis. attending instruction by Power.Prospective descriptive Intubation with Bul. 80.5 2007 a complex motor lard laryngoscope study lard laryngoscope. showed without the use of anesthesiologists. of correct responses tasks than control group. residents who did 4-d training period. 1 al. VR airway simulator skills all residents who cadaver at 2 wk after seems to offer effective tool for training in used VR simulator training FOI and may offer tool for assessment of for 1-wk period (n = readiness before trainees attempt technique February 2012 11).17 Exploration of how 22 first-year anes-Baseline assessment of Pediatric and adult No. of correct diagnoses. attend. per- improve anesthesia training (n = 11). practice enced in use of Bul. performance respiratory events to comprehension ques. time to AANA Journal  tor can be used to not use the VR sim.249). tic training with scenarios were time tory events addition of PTT andlimited. scenarios. time group (P < .anesthesia resi. US Licensure control group. assembled and www. lard laryngoscope endotracheal tube. nario and a fresh human ing group (P < . Competence evaluated Course completed in ≤ 21 min. virtual reality FOI sce.aana. on live patients  ing anesthesiolo- gists (n = 4) Mackenzie et Compare perfor. Point (Microsoft.14 1996 mance of deficien. All metrics improved in both groups. and manikin head also used Goldmann and Test the hypothesis Medical residents. Type of airway Outcome measures Study Purpose Sample Design simulation or results Conclusion Johnson et al. diagnosis from baseline (P = . only significant in novice 2006 (VR) airway simula. most frequent deficiency. management as cies. 28 performance defi. blinded observers Pott and Determine whether Novice users of Bul. prepare scope and intu.aspx skill can be taught (n = 28). via a checklist. Bullard laryngoscope. 27 continues on page 4 . successful Santrock. airway and other no.001).

from DAS guidelines from guidelines at 6 - 8 wk only. based on “ideal” man.05). simulation drill is replicated pected difficult simulation group tion intubations (n = 20). CI scenario: Significant increase in time al. Controlled prospective Intubation using air. sustained improvement ficult airway and/ training on the Difficult in technical skills of cricothyroidotomy (P or ventilation. formance deficiencies cedure. ios scored by 1 observer to insert laryngeal mask airway (LMA) or on compliance with study. and noted on the anesthesia use of a no-fault self-reporting mechanism AANA Journal  analysis posttrauma treatment record. wk and 6-8 mo after can ventilate (CI) nario: Significant. failure to adhere to operating room pro- by 3 types of self. hazards of anesthetists in intubation by stan. PTQ identified may be useful questionnaire (PTQ) 8 of 11 cases in which compared with video deficiencies were noted analysis by video analysis Goldberg et Evaluate the risk 40 patients ran. 1 of a difficult airway simulated and per- formed with the aid of endotracheal introducer Kuduvalli et Measure the 21 British anesthe.05) Table 1. anesthesia 2008 effects of training tists control interventional simulated patients: 1. or pulmonary aspira. 2 deficiencies performance deficiencies and their factors. no per. Prospective case. intubating LMA at 6 - 8 month interval (P national guidelines 2 scenarios measured not ventilate (CICV).aana. EI. esophageal intubation posed by EI should be considered before dealing with unex.001). In both scenarios. arrhythmias. cannot intubate. 2 scenarios in adult Management of scenar. which was no longer present at 6-8 performance over mo. use of video analysis to identify report with those the anesthesia quality noted. no significant reduction in mean specifically. Risk assessed by No significant differences between the al. significant reduction in deviations for management of at baseline and 6-8 2. 5 EIs in the simulation group and none  increase the skill group (n = 20). identified by video assurance report. significant reduction in deviations time from guidelines at both times (P < . (EI). effect algorithm duration of oxygen saturation from base- of formal training on line. agement plan derived < .aspx .05). groups in any outcome indicators except February 2012 drill designed to 2 groups: control oxygen saturation. can. more Airway Society (DAS) < . CICV sce- unanticipated dif. 80. performance in cannot intubate. continued from page 3 28 Type of airway Outcome measures Study Purpose Sample Design simulation or results Conclusion agement captured identified by the by video analysis. in the control group (P = . No. ischemia.13 1990 of a simulation domly assigned to study way adjunct changes in vital signs. dard techniques.05). intubation Vol. Review of Clinical Research Studies of the Use of Simulation as an Educational or Evaluation Tool to Enhance Training of Anesthesia Providers in Difficult Airway Management www. sustained reduction in improper use of equipment (P < .

For example.3. Analysis of performance based on generally accepted “time to completion” not to be sensitive enough to detect guidelines using several different reporting modalities14 improvement in overall skill performance. They concluded that training should be fully in the abstract. Gyrus in the United Kingdom.8.6. of simulation as a tool to teach advanced airway manage- erogeneity. Self-instruction formance using guidelines developed by the Difficult via a PowerPoint (Microsoft. and prehospital airway management.9. As with all systematic reviews. patients. 80. the outcomes of these studies support the ment to anesthesia students and current practitioners.7-12 5.9. ACMI.13 by only 1 study.7. Single and multiple measures of performance com. Fidelity to the actual to identify a study of the effects of simulation on skill clinical environment was considered key in developing improvement and retention for management of a patient the specifics of the simulated scenario. retest but not at the subsequent 6.14 and the use of a group of nonnovice anesthesia providers. Kuduvalli et al16 examined the establishment of a mask airway during an arrest sce. effects on management of a patient with a difficult airway nario. Simulation has been used for airway management train- ing by multiple medical and allied health groups. Although they did not find a signifi- of the training was to achieve competency in complex de- • Difficult Airway Algorithm (DAA).16. and computer-based trainers. Southborough. and all of unanticipated difficult intubation in adult nonobstetric learners were deemed competent after training.17 design. An analysis of the effects of nonhuman interfaced provide support for techniques that may be used in the simulation5. and/or pared with a predetermined checklist3-7. We identified 1 such study single complex motor skill (Bullard laryngoscope. The authors used a structured approach and found erature review depends on the appropriate use of search that training effects were sustained at a 6. Study Recommendations designs to evaluate the use of this training and teaching Additional research is needed to further evaluate the use method have varied widely (Table 2).16. scenario-based simulation training for airway management of trauma patients. Washington) Airway Society of the United Kingdom for management presentation and a part task trainer were used.5 using whole-body. An evaluation of the types of methods used to assess safety and the transition of skills from the laboratory to performance deficiencies14 the clinical setting. virtual reality. between simulated performance of fiberoptic intubation lated experience11 and clinical skills. Specific types of airway management evaluated included The task being taught. the accuracy of a lit- ing. Despite their het. 1 29 . Simulation can include the use of whole body. time flexibility seem to be the most important variables tions.10.17 the potential or actual effects of this training on patient 6. Redmond.aspx AANA Journal  February 2012  Vol. Our review failed cision making and advanced skills. Kuduvalli et al16 evaluated per.17 time to completion of a task. part Types of Airway Management Evaluated trainers. some relevant studies might have repeated at 6-month intervals or less.aana. Of the outcome variables used to • Outcome Measures. The ways these skills trans- 2. No. been missed. if not described with training.15 DAA for anesthesia providers. A study of the effects of an actual human-based Few studies established a valid method of evaluating simulation4. most used objective measures of performance. including a weighted and nonweighted checklist. all participants underwent simulation-based train.15 assessment skills and airway management of to consider in developing the most effective simulation unanticipated adult and pediatric difficult airways. they believed their outcome measure of 5. Although we endeavored to use the broadest search terms They also found a reduction in the misuse of equipment and worked closely with a 8-month retest. the availability of trainers.15 and lated to bedside care and patient safety were investigated number of Time to completion of a specific task4-7. findings of The DAA has been suggested as a potential basis on this systematic review confirm that simulation may be which to design the simulation and subsequent evalu- www. Subjective and/or self-perceived value of the simu.10. 1. The aim of the study was to evaluate the decay of the effects of training over time. In this case-control Limitations of the Review study. effectiveness of this training modality. Thus.11 fiberoptic intuba.lators and techniques on learning13 an effective tool to teach airway management skills and 4. Standardized outcome criteria by which to measure the effects of training are notably dissimilar in Discussion the studies. Measurement of efficient and nonefficient time4 cant correlation. The purpose an airway adjunct.9-12 use of a specific intubation laryngoscope. Crabtree et al6 studied the correlation 8-week terms and search procedures for the databases searched. Outcome measures varied greatly detect learning in the simulation laboratory included in and included the following: the review.8. Massachusetts). Pott and Santrock5 with a difficult airway using the nationally recognized studied the effectiveness of simulation in developing a DAA from the United States.

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