Teaching Airway Management Outside the Operating Room

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Chapter 52 Teaching Airway Management Outside the Operating Room

Sebastian G. Russo, Stephen F. Dierdorf

I Background

Management of the airway is the most important and potentially the most life-saving (or life-threatening) task that an anesthesiologist, emergency department (ED) physician, or intensivist performs. Missteps in airway management can result in mortality or significant morbidity. In 1985, the American Society of Anesthesiologists (ASA) Committee on Professional Liability began to analyze closed-claim malpractice cases to objectively assess adverse outcomes from anesthesia. The initial analysis of the data, published in 1990, revealed that respiratory events accounted for 34% of the claims (522/1541 cases) and that 85% of the respiratory events resulted in permanent neurologic injury or death.¹ Three mechanisms of adverse outcome from respiratory events accounted for 73% of the events: inadequate ventilation (38%), esophageal intubation (18%), and difficult endotracheal intubation (DI; 17%).

The reviewers concluded that 90% of the cases of inadequate ventilation and esophageal intubation could have been prevented if monitoring with capnography and pulse oximetry had been employed. It was also concluded that only 36% of the cases of DI were easily preventable. In response to this finding, the Task Force on Management of the Difficult Airway (DA) was formed by the ASA. After an exhaustive search and evaluation of the medical literature concerning airway management published between 1973 and 1991, the task force published Practice Guidelines for Management of the Difficult Airway in March, 1993.² These guidelines included recommendations for evaluation of the airway, basic preparation for DA management, strategy for intubation of the DA, and postoperative care. The Task Force also developed an algorithm for management of the DA. Updated guidelines, based on information accrued since 1993, were published in 2003.³ It can be anticipated that future updates based on experience with new airway devices will occur.⁴ Other organizations with interest in airway management have also published airway management guidelines.⁵

A Is There Evidence That the Difficult Airway Guidelines Have Been Effective in Reducing Adverse Airway Events?

A review of the closed claims database in 1999 revealed a decline in claims for adverse respiratory events, primarily related to a reduction in claims for inadequate ventilation and esophageal intubation.⁶ Claims for adverse events secondary to DI remained relatively constant, and claims for trauma to the upper airway increased. The claims for pharyngeal and esophageal trauma were frequently associated with DI. Another study, published in 2005, compared claims for DA management during two time periods: 1985–1992 (before DA guidelines) and 1993–1999 (after DA guidelines). Claims for adverse respiratory outcomes (death or brain death) during induction of anesthesia decreased by 67% during the latter period compared with the former. However, claims for similar adverse respiratory outcomes occurring during the maintenance phase of anesthesia, at extubation, or during recovery did not change.⁷

Although respiratory events are more likely to result in an adverse outcome, the incidence of patients with a DA in clinical anesthesia practice is actually quite low. The incidence of failure to intubate the trachea in a large series of surgical patients was only 0.3%.⁸ Although the most comprehensive published data have concerned perioperative airway management, airway management in the prehospital setting, in the ED, and in the intensive care unit (ICU) is no less important and must be included in any airway education program.⁹ Airway management is not an easy skill to learn, and educators must give careful consideration to the complexity of airway management and the ability of different types of health care providers to manage ventilation and endotracheal intubation.

Objectives for education in airway management include the theoretical and practical aspects of airway devices and techniques and a time-based environment that mimics actual clinical situations. The student must also gain an appreciation of the relationship between the practitioner and the patient and the effects that clinical decisions may have on outcome.¹⁰ The teaching program must allow the learner in a nonclinical environment to make choices that may result in an adverse outcome.

II Miller’s Learning Pyramid

An airway teaching program must teach simple maneuvers (e.g., performing a jaw thrust) as well as complex skills such as awake fiberoptic intubation (FOI). The design of a successful education program begins with the development of clear objectives. What has to be taught, to whom, and how? The program must also address different knowledge and skill levels. Miller’s learning pyramid for assessment of clinical skills has four stages of ability: Knows, Knows How, Shows How, and Does (Fig. 52-1).¹¹

Figure 52-1 Level of competence based on clinical assessment. The highest level of competence, Does, is ultimately achieved with clinical performance.

(Adapted from Miller GE: The assessment of clinical skills/competence/performance. Academic Medicine 65, S63–S67, 1990.)

An example of this pyramid can be applied to use of the laryngeal mask airway (LMA). The first level, Knows, is the knowledge that there is a need for airway management and that the LMA can be used for that purpose. Knows How is the knowledge of how to prepare and insert the LMA. At the next competence level, the learner Shows that he or she is capable of inserting the LMA. The highest competence level, Does, reflects transfer of the new skill (LMA use) to the clinical situation. The first three levels of the learning pyramid can be achieved with didactic lectures, video observation, computer programs, and skill-training with mannequins, animal models, or cadavers.

Because skills and scientific information gained during simulator training may not be easy to transfer directly to clinical practice, the clinical environment is the best environment for developing airway management skills.¹² Practicing techniques such as airway assessment, bag-mask ventilation (BMV), supralaryngeal airway (SLA) insertion, direct laryngoscopy, and FOI in actual patients would be ideal. The highest competence level (Does) in airway management ultimately requires practice in the clinical environment. There are, however, a number of barriers to training exclusively in the clinical arena (Box 52-1). Training outside the operating room (OR) or ICU is done to minimize the risk to patients and promote efficient clinical learning.

III Computer-Based Learning

The pace of development of interactive computer-assisted instructional programs has surpassed simulation development over the past 10 years. Computer-assisted instruction can facilitate the organization and linkage of information directly applicable to clinical situations.¹³ A major advantage of computer-based instruction is the low cost after development and the lack of need for a human instructor. The learner can use the program at his or her own pace and as many times as necessary to achieve mastery of the subject. The increased power of laptop computers has reduced the need for computer centers and provides the learner with exceptional mobility. Computer-assisted instruction can also provide alternative learning methods for students who do not learn well with traditional teaching methods.

A clinical department can develop its own instructional programs or access existing programs via the Internet. The number of Web sites relevant to anesthesia continues to grow, and the Internet provides rapid access for users in remote locations.¹⁴ However, Internet programs are not peer-reviewed, and quality can be variable.¹⁵ The transition from Web 1.0 to Web 2.0 has encouraged more interactivity and improved the quality of Web-based education.¹⁶ The disadvantages of Web-based education, such as insufficient feedback and instructional ambiguity, can be overcome by providing local faculty input to supplement the Web-based program.

Technical assistance may be required for the clinical faculty to facilitate in-house program development. The potentially daunting task of program assembly and maintenance must not be an obstacle to the faculty.

There are several objectives of an interactive airway management program (Box 52-2). One is to familiarize the learner with the anatomy and physiology of the upper airway. The complexity of the upper airway is often overlooked, and understanding of upper airway function can provide an early warning of impending respiratory difficulty. The structure and function of various airway devices can be displayed with diagrams, photographs, and videotapes. Computer-based multimedia programs can demonstrate device function and technique with a much more effective presentation than a traditional lecture format.

After the basic principles of airway management have been presented, interactive programs can be directed to elucidate the intricacies of the DA algorithm so that the learner understands the critical decision points during the course of airway management. A library of actual airway abnormalities can be loaded onto the computer as an additional teaching tool. Most modern video laryngoscopes (VLs) and flexible fiberoptic bronchoscopes (FFBs) can record airway examinations and airway device insertion. The combination of text material and narration with imported diagrams, photographs, and videotapes can be used to explain concepts and airway management techniques in considerable detail. More advanced interactive programs can simulate the clinical environment and present actual clinical scenarios in a real-time environment that permits the student to halt the program and access information that may affect the decision process. Such scenario-based learning is becoming increasingly important in medical education.

IV Efficacy of Simulation in Education

Simulation has been used for decades to address training problems in high-risk disciplines such as military science and aviation. Medical simulation began in the mid-1990s and has grown rapidly.¹⁷ Simulator training programs incorporate psychomotor and decision-making skills that address the highest level of competence in Miller’s pyramid: Does. When the programs are appropriately designed, simulation can close the gap between acquisition of skills and meaningful use of the acquired skills (Fig. 52-2). This may be especially true for rare situations. Because the incidence of the DA is low in clinical practice, two questions must be addressed: How can an anesthesiologist in clinical practice learn new airway skills? and How can the ramifications of critical decision points in airway management be learned?

Figure 52-2 Indications for use of different training tools in the acquisition of technical and nontechnical skills based on Miller’s learning pyramid. The width of the pyramid should reflect the benefit of the distinct training tool on the indicated level of competency.

The inherent nature of airway management includes uncertainty, complexity, time pressure, and high costs for failure. Simulation provides the ideal method for closely replicating the clinical situation and may help to scientifically evaluate strategies, decision points, and algorithm adherence.^18,¹⁹ The efficacy of education with medical simulation is well established, but its effect on reducing the incidence of adverse patient outcomes is more controversial.^18,²⁰^–²⁴ It is easy to prove the effect of a theoretical lecture or workshop with a pretest and post-test. It is not easy to prove the effect of simulation on patient outcome in rare but life-threatening situations such as the DA. Nevertheless, there is evidence in the literature that simulator- and scenario-based training improves patient care.

V Types of Simulators

Simulators can be classified as low-fidelity (static) or high-fidelity (dynamic).

A Low-Fidelity Simulators

Skill-trainers or mannequins are available for most airway devices, such as conventional laryngoscopes, SLAs, and FFBs. Skill-trainers are designed to teach specific motor skills, such as direct laryngoscopy, the fundamentals of FFB guidance, or SLA insertion.

Mannequins do not always accurately replicate human anatomy and cannot be altered to represent abnormal anatomy. Such low-fidelity simulators provide neither physiologic data nor clinical feedback for the learner. Despite these shortcomings, however, effective skill transference to clinical use may be facilitated.²⁵

B High-Fidelity Simulators

High-fidelity simulators, more commonly referred to as human patient simulators, offer many advantages over low-fidelity simulators. Physiologic parameters such as blood pressure, heart rate, pulse oximetry, capnography, breath sounds, peripheral pulses, and temperature can be programmed into the simulator. High-fidelity simulators cannot accommodate the variations in human anatomy.²⁶ This is especially true for DI scenarios in which insertion of an SLA may be clinically effective. The reason is that the DI scenario in the simulator is created by supraglottic obstruction rather than laryngeal displacement.

Current simulators have pre-programmed clinical scenarios that require no program assembly and minimal technical expertise on the part of the instructor. The teaching programs present time-based physiologic changes in the simulator that accurately reflect actual clinical events. The programs allow the learner many different management choices, and the instructor can vary the simulator’s physiologic responses based on the learner’s selection of techniques. Human performance deteriorates during periods of stress, and there is a tendency to revert to old behavior patterns. Translated to airway management, this may result in repetitive attempts to use airway techniques that have previously failed (e.g., rigid direct laryngoscopy) while the patient’s condition continues to worsen. Simulation can be used to teach new management techniques, and permits the learner to apply those techniques in a simulated environment in which the adverse effects of a poor choice will be evident. Repetitive simulated encounters can then be employed until the new technique becomes part of the learner’s management armamentarium. High-fidelity medical simulation can create a learning environment that supports experiential and reflective learning. For this purpose, a realistic scenario based on a real-life situation is introduced into an authentic environment, followed by a structured debriefing about strategies the learner chose. Appropriate simulation teaching programs help the student develop integrated emotional, cognitive, and psychomotor abilities that effect a change in behavior and performance in the clinical setting. These advantages offset the initial capital investment, need for training space, and operational costs.

Many medical institutions and health care consortiums have invested in multipurpose simulation centers to provide training for different types of health care providers. These centers replicate ORs, ICU beds, ward beds, examination rooms, and ambulance bays to provide a realistic setting for trainees (Fig. 52-3). Simulation centers can employ full-time technicians to manage the technical aspects of simulation. This allows the teaching faculty to concentrate their efforts on curriculum development and the direction of simulation sessions.

Figure 52-3 A, A simulated operating room (OR) equipped with a high-fidelity human patient simulator. B, The control room of the simulated OR. The trainer can orchestrate the simulator session from the control room while observing the trainee’s performance through the one-way mirror.

Trainees from many disciplines need experience with simulation education. Licensure and board accreditation examination systems are rapidly incorporating an evaluation of performance with high-fidelity simulation.²⁷^–²⁹

VI Airway Management Skills

There are several skills that the experienced airway provider must acquire in order to provide comprehensive airway management. Airway management skills are not easy to learn, the time to apply those skills to the apneic patient is short, and the risks of failure include death or permanent neurologic injury.³⁰ Traditional educational programs depend on the accumulation of clinical experience, which may take years. Structured simulation-based teaching should provide a broader experience in a shorter period of time, thereby improving the airway management skills of a greater number of providers.

The instructor must determine what level of skill a particular provider must possess to meet his or her expected need. A gastroenterologist administering or supervising the administration of medications for conscious sedation does not require the same level of airway management expertise as the ED physician or the anesthesiologist. There is considerable variation in the airway skills of first responders, and the rescue airway techniques that are to be applied by first responders must be determined in the early planning phase of the teaching program. The instructor must design an educational program that meets the objectives for each type of student. The program will consist of the didactic material that explains the theory of the skill and describes how the technique is employed. After the theory is understood, the student can learn and demonstrate proficiency with static simulators (mannequins). For some skills, proficiency with a static mannequin is all that is required; other skills may require additional simulation experience before clinical application.

One of the challenges in designing a course for airway instruction is the myriad of devices and techniques that are commercially available. It is not possible for an institution to have all devices available, nor is it possible for an individual to be proficient with every device. Practitioners need to be selective in choice of airway devices based on the patient population served and the resources available from the institution. Proficiency with one type of device from each category is satisfactory for most situations.

A Bag-Mask Ventilation

BMV is an important airway management technique that does not receive as much attention as it deserves. A major determinant of successful resuscitation of an apneic patient is the rapidity with which the first responder can establish effective ventilation. The student should know the effect of the unconscious state (whether drug or disease induced) on the upper airway and how this produces airway obstruction. Relaxation of the pharyngeal muscles and tongue obstructs the hypopharynx and allows the epiglottis to obstruct the glottic inlet. Elevation of the mandible lifts the tongue off the posterior pharyngeal wall and moves the epiglottis away from the glottic inlet, thereby opening the airway. Compression of the face mask against the face to produce an airtight seal permits positive-pressure ventilation (PPV) via the unobstructed airway. After the student understands these basic principles, instruction with a static mannequin demonstrates the actual technique of BMV. When the learner can demonstrate proficiency with the mannequin, he or she is ready to apply the skill to patients.

Since the LMA entered clinical practice, there has been concern about loss of BMV skills. Practice of this technique can occur in the OR while neuromuscular blockade takes effect. Also, very short procedures could continue to be performed with mask ventilation rather than light ventilation.

An additional exercise that is highly instructive is teaching the students to use BMV on each other. Augmented ventilation of the conscious patient allows the student to learn how to synchronize gentle PPV with the subject’s inherent inspiration. After a short period of supplemental hyperventilation, the learner can completely control the conscious subject’s ventilation.

B Pharyngeal Airways

Pharyngeal airways, including oropharyngeal and nasopharyngeal airways, are designed to provide a patent passage through the mouth and hypopharynx by elevating the tongue and epiglottis. Pharyngeal airways are simple in design but extremely effective for alleviating upper airway obstruction. Insertion of a pharyngeal airway and two-person ventilation can provide effective ventilation in some of the most challenging DA cases. The use of pharyngeal airways can be easily integrated into the instructional program for BMV. Any medical provider who may encounter upper airway obstruction should be proficient with the use of pharyngeal airways.

C Supralaryngeal Airways

Effective use of SLAs requires a higher level of expertise than the use of pharyngeal airways. There are many manufacturers that supply SLAs, and insertion techniques vary. All SLAs are purported to provide a secure airway with a seal adequate for PPV. However, many SLAs have not undergone rigorous investigation before market release. Such devices may not survive the rigors of clinical practice and may be withdrawn from the market subsequently. Course design should focus on the concepts that are central to all SLA devices. Didactic material presented to the learner should explain the rationale for the device’s design and provide complete description of the insertion technique and correct positioning of the SLA in the upper airway. The learner must also understand the procedures for confirmation of correct placement and potential complications before clinical application of the technique. Users with an incomplete knowledge of potential difficulties are likely to encounter some complications. Despite the risk of complications, SLAs have a high success rate for establishing effective ventilation during resuscitation.

The LMA has been shown to be an effective device for emergency ventilation when used by relatively inexperienced providers. First responders should be trained in use of the LMA as an early intervention. The medical literature concerning effectiveness of the LMA during resuscitation is extensive. Whether such effectiveness can be achieved with other SLA devices has not yet been proven, but the supposition seems likely.

Information that the learner should acquire during the initial phase of the training program includes the structural function of the device and correct insertion and positioning. Common to all SLA devices is their insertion over the tongue, into the hypopharynx, and above the glottic inlet. Although the type of SLA employed varies from institution to institution, it is beneficial to provide training with different SLA devices. There are several mannequins available for SLA insertion training, but performance varies, and the instructor must select one that is suitable for the particular device used.³¹

The depth and intensity of SLA training depends on the level of performance that is desired, and the goals for each type of medical provider must be clearly delineated. Anesthesiologists, who require the highest level of performance, must invest considerable time in mastering the use of the LMA. There are two learning curves: an initial learning phase consisting of 50 to 75 insertions, and a slower learning phase encompassing hundreds of insertions.³²^–³⁴

D Conventional Direct Laryngoscopy

Conventional direct laryngoscopy has been a mainstay for airway management for decades and is considered by many to be the gold standard for emergency airway management. Skill development for direct laryngoscopy is difficult and requires more experience than previously thought.³⁵ Numerous studies have demonstrated that alternative airway techniques, such as placement of an SLA, actually result in more rapid and effective ventilation than endotracheal intubation with conventional direct laryngoscopy. Such observations have caused many airway educators to change how they teach emergency airway management.³⁶

The rigid, direct laryngoscope is designed to align the three axes—oral cavity, hypopharynx, and larynx—so as to establish a line of sight for passage of an endotracheal tube. Line of sight is achieved by depressing the tongue and sublingual tissue with the rigid laryngoscope blade into the submandibular space. Anatomic variations such as abnormal or carious dentition, a small mandible, lingual tonsillar hyperplasia, reduced cervical mobility, and obesity may reduce the effectiveness of the rigid laryngoscope in developing a line of sight. The application of excessive force to the upper airway can cause significant injury. Insertion of the laryngoscope blade and points of force application require subtle skills that are not easily appreciated by the novice with mere observation. A methodical instruction program that includes guided clinical experience is necessary. It is no longer acceptable for learners to begin direct laryngoscopy by intubating patients.

A training course for providers who have little or no experience with conventional direct laryngoscopy should begin with lecture material that includes upper airway anatomy and physiology, the mechanics of direct laryngoscopy, and sequential instruction on the intubation process. Models have been developed that can be adjusted to reflect anatomic variants so that the student can see the effects of these variants on intubation technique.³⁷ Mannequin practice with a VL has been shown to improve the success rate for intubation of patients.³⁸ A clinical instructor should expect all novices to have extensive simulated experience before patient exposure. Selection of appropriate patients (such as lean, edentulous patients followed by patients with normal dentition) enhances the experience while reducing the likelihood of patient injury. Endotracheal intubation of patients who are likely to have rapid arterial oxygen desaturation, such as obese patients or children, should be done only after the learner has accumulated significant experience.

E Video Laryngoscopy

Advances in imaging technology have spawned a new class of intubation devices, the VLs.³⁹ VLs continue to be refined and may in the future become the instrument of choice for all endotracheal intubations. The Bullard laryngoscope was introduced many years ago and was perhaps the first VL to have significant clinical application. The refinement of other imaging techniques has generated an increase in the number of different VLs now available. The basic components of all VLs are a rigid, anatomic blade and an imaging device that provides a view of the larynx without requiring line of sight. The important advantage of such a design is that it permits a reduction in the force that must be exerted by the laryngoscope blade on the patient’s upper airway in order to see the glottic inlet.

Although the blade of the VL resembles the blade of a conventional direct laryngoscope, the insertion techniques for the two devices are different. A conventional direct laryngoscope blade is inserted in the right side of the mouth with the tip of the blade directed toward the right tonsil bed. The blade is then redirected toward the midline and advanced until the epiglottis is seen. Once the epiglottis is visualized, the blade can be advanced into the vallecula or underneath the epiglottis to expose the glottis. The VL, on the other hand, should be passed over the tongue in the midline and advanced until the epiglottis appears. The blade is then advanced into the vallecula and rotated slightly anterior, which elevates the epiglottis and permits a good view of the glottis.

Even experienced laryngoscopists do not appreciate the differences in technique when they first use a VL. Comparative studies of various laryngoscopes provide information about performance in different scenarios, and students should be exposed to several VLs so they can determine which one is best for them.^40,⁴¹ Once the technique of video laryngoscopy has been mastered, many prefer it to conventional direct laryngoscopy for even routine endotracheal intubations.

F Fiberoptic-Assisted Endotracheal Intubation

Fiberoptic-assisted endotracheal intubation (FOI) has revolutionized management of the DA. FFBs for airway management began to be used in anesthesia practice in the 1970s but initially did not gain widespread acceptance. The problem was a lack of effective training of anesthesiologists. In most cases, the FFB was used only when a DA was anticipated and the plan was for an awake intubation. The clinical situation, consequently, was an inexperienced endoscopist, an abnormal airway, and an awake, uncomfortable patient. The outcome was not likely to be pleasant or successful. It was not until creative airway management teachers developed effective teaching programs that FOI became a routine part of resident education.^42,⁴³ Although much progress has been made with resident education, there is still inconsistency among residency programs with respect to FOI.⁴⁴

Performance of FOI is a skill that every advanced airway management provider should master. Although the process by which providers are taught this skill has not been standardized, there is sufficient evidence in the medical literature to provide guidance for instructional development. A department’s or institution’s ultimate training system may be influenced by financial and manpower resources. There are low-tech and high-tech models and simulators that can be used. Do skills learned with models and simulators transfer to clinical performance? Resolution of this question is central to the efficacy of medical simulation education and remains controversial.⁴⁵ The preponderance of evidence concerning FOI affirms the theory that there is significant skill retention and transference.⁴⁶^–⁴⁸

The course for FOI should begin with didactic material that describes upper airway anatomy, FFB construction and operation, and the fundamentals of FFB manipulation. This material may be presented in a traditional lecture format or via a computer program. The next phase of the program must permit the learner to practice FOI. This can be accomplished with static mannequins of the head and neck or with simple, nonanatomic models that require the learner to recognize objects or numbers after FFB manipulation. These models can be constructed with boxes or tubes that require the learner to visualize the images through the FFB during the process of FOI (Fig. 52-4). More realistic static mannequins are also available (Fig. 52-5). The video bronchoscope is a very useful device because the instructor can observe the intubation process on the monitor and offer suggestions to the learner as the intubation progresses (Fig. 52-6). Modern video bronchoscopes produce a high-resolution, wide-angle image of the airway. Teaching with a video bronchoscope improves the rapidity and success of endotracheal intubation by anesthesiology residents.⁴⁹

Figure 52-4 An inexpensive and easily constructed model of a tracheobronchial tree made from anesthesia circuit tubing.

Figure 52-5 An anesthesiology resident practicing fiberoptic intubation with a static mannequin.

Figure 52-6 A resident practicing guidance with a flexible fiberoptic video bronchoscope on a mannequin under faculty supervision.

There are high-fidelity simulators specifically designed for FFB training. These simulators accurately reproduce the responses to the user’s manipulations, including mucosal bleeding, coughing, and laryngeal motion with respiration. Goldman and associates demonstrated that virtual reality–trained novices quickly learned FFB manipulation, and after a short training period, they performed as well as experienced attending anesthesiologists.⁵⁰ A high-fidelity simulator can replace the need for practice with animal and cadaver models. High-fidelity simulators are expensive and may not offer significant advantages over less expensive models. Virtual reality computer programs may provide the same benefits as high-tech bronchoscopic simulators.⁵¹

After the student has mastered the extraoperative phases of the training program, he or she is ready to begin clinical training with oral FOI of lean patients with normal airways receiving general anesthesia.^52,⁵³ This part of the training emphasizes FFB navigation, management of secretions in the airway, and passage of an endotracheal tube over the FFB. This teaching program works just as well for pediatric patients.⁵⁴ The time required to become competent with FOI varies from resident to resident. Some may be very capable after 10 to 15 successful intubations, whereas others may require 25 to 50 intubations.⁵⁵ After a resident is competent with FOI of normal patients, he or she can progress to patients that can be easily ventilated after induction of anesthesia but in whom laryngoscopy is difficult.

After proficiency with FOI of anesthetized patients can be demonstrated, the learner is ready to progress to awake intubation. The entire educational process can be completed in 4 to 6 weeks by most anesthesiology residents—a relatively short time to acquire such a valuable skill (Box 52-3). The challenge for residents from other specialties is having enough clinical opportunities after completing simulator training. Collaborative efforts among anesthesiologists; intensivists; ED physicians; ear, nose, and throat surgeons; and pulmonologists are required to meet the educational needs of all the appropriate disciplines.

Education of practicing clinicians who did not have formal training in FOI remains a significant challenge, because the pressures of clinical practice may not allow time for graded patient experience. Many attendees of educational fiberoptic workshops report an extremely low rate of clinical application after the workshop. The ultimate solution for this group of clinicians may be high-fidelity simulation training at a simulation center followed by experience with more recently trained clinicians as they join the practice group.

G Invasive Airway Techniques

Invasive airway techniques are difficult to practice because of limited clinical opportunities. Although mannequins do not accurately replicate the clinical scenario for most invasive airway techniques, mannequin practice does allow the learner to practice the sequence of steps for emergency invasive airway management. Some institutions employ fresh cadavers, isolated animal tracheas, or anesthetized animals as models for invasive airway insertion (Fig. 52-7).^56,⁵⁷

Figure 52-7 Percutaneous identification of the trachea with needle aspiration through the cricothyroid membrane of a human cadaver. This is the initial step in emergency cricothyrotomy.

The necessity for emergency invasive airway procedures has undoubtedly been diminished by the development of SLAs and VLs.⁵⁸ This is fortunate in that providers with minimal invasive experience do not have a high success rate with invasive airway techniques and can encounter significant complications when performing them.⁵⁹ However, there are still situations in which all noninvasive methods have failed and an emergent, invasive airway technique is required.

H Comprehensive Airway Management

The final step for educating individual medical providers who need broad airway skills, such as anesthesiologists, ED physicians, and critical care physicians, is a clinical rotation focused on airway management problems. The traditional approach to clinical airway training was based on the concept that each resident would acquire sufficient exposure to airway cases during residency (apprenticeship model). This teaching model promotes inconsistency among programs and individual inconsistencies within programs. Professional anesthesiology organizations have failed to provide specific guidelines for training in airway management. More progressive educators have instituted airway rotations in their residency programs to expose all residents to a wide variety of airway devices and techniques.⁶⁰ As more clinicians who have had comprehensive airway training enter clinical practice, their training should provide a springboard for further professional development.⁶¹

Simulation can be employed to evaluate team performance and institutional protocols.^62,⁶³ This methodology will assume increasing importance as health care institutions merge into larger organizations and become more process oriented. For many processes it is yet unknown whether patient outcome is significantly improved, therefore a validation of their merit is required. Multidisciplinary simulated exercises may expose deficiencies in institutional procedures for management of high-risk patient events.

VII Conclusions

Clinical teaching of airway management on actual patients is irreplaceable. However, the risk of complications is increased when novices are being taught airway management methods. Learning the fundamentals of airway management outside the OR, ED, or ICU better prepares the learner for clinical experience. The educator will find that outside instruction renders the clinical teaching experience more efficient with reduced patient risk. The development of powerful personal computers and high-fidelity simulators permits the construction of interactive programs with realistic clinical scenarios that mimic actual patient experiences. These tools allow the learner to participate in simulated airway events and to practice repeatedly until the management concepts and airway techniques are mastered.

It is imperative that instructional courses be tailored to the skill level of the learner and that clear objectives be elucidated during the process of course design. Extraoperative instruction can occur with an integration of traditional teaching methods, computer programs, low-fidelity and high-fidelity simulators, and animal models. The development of virtual reality computer programs and simulators is progressing at a rapid pace. Some airway management skills are difficult to learn, and robust instructional programs must become an integral part of residency training. Coordination of nonclinical and clinical instructional programs will ensure effective acquisition of airway management skills with minimal risk to patients.

Training programs should develop simulation-based education curricula.⁶⁴ Instruction in airway management is well suited for simulation. An alternative to developing an in-house simulation center is to use established simulation centers. The ASA has developed a process for simulation center endorsement, and the network of endorsed simulation centers continues to expand. There is little doubt that medical simulation at all levels of complexity has become an integral part of medical education.