It is sometimes striking how difficult it is to teach airway management well, and to have the student learn it, even with a comprehensive immersion experience in airway management. This text serves as the syllabus for an airway management education program that places special emphasis on the identification and management of the difficult and failed airway. This program, which has trained over 10,000 emergency airway practitioners, has undergone progressive improvement and innovation, and is now called The Difficult Airway Course: Emergency™. It is one of a family of educational programs that now includes: The Difficult Airway Course: EMS™, The Difficult Airway Course: Anesthesia™, The Difficult Airway Course: Critical Care™, The Difficult Airway Course: Residency Edition™, The Difficult Airway Course: Fundamentals™, and The Difficult Airway Course: Custom™.
Gas exchange is fundamental to airway management. Thus, an educational program intended to teach airway management must craft educational objectives that support this fundamental goal. These “enabling objectives” are crafted in language typified as: “By the end of this educational program the participant will….” The program of instruction must embrace the knowledge and skills that constitute the current standard of care, and, in addition, teach best practices related to the provision of gas exchange for those patients who are unable to do so for themselves.
This chapter serves as a primer for an airway management education program that academic as well as private practice practitioners can apply to their practice to improve both their airway management skills as well as the skills of their health care team. This chapter places special emphasis on the application of simple, easily applied hands-on experiences to improve the identification and management of the difficult and failed airway.
The objectives of a comprehensive airway program should contain five easily identified components. These are:
The results of a local needs assessment identifying training issues as well as a focused curriculum.
A cognitive or didactic component: maybe accomplished with either a self-guided reading program or a series of focused lectures.
A skills development component: a “hands-on” laboratory that teaches the nuances of the devices identified as “the standard of care,” and other relevant devices as supported by the local needs assessment, as well as best practice based evidence or expert consensus.
A practical real-time experience: an opportunity to “put it all together” with hands-on cases that simulate a real-life situation.
An evaluation process of the program and a self-evaluation process for the participant.
This chapter will focus on providing guidance for the development and execution of an airway management/difficult airway educational program in one’s own home institution. The following areas will be discussed:
The evidence that simulation works, improving patient safety through education, training, and research.
A detailed review of the devices a practitioner might easily use to start a local simulation program.
A curriculum focused on a needs assessment for your institution and the acquisition of requisite skills.
A skeleton for a “Context-Sensitive” Training program—that is, “point-of-care” or “in situ” simulation.
Airway management is the scaffolding upon which the whole practice of anesthesia is built, and is also part of other practitioners’ practice, such as emergency physicians, critical care specialists, hospitalists, and pre-hospital practitioners.1 Important as excellence in airway management has become, equally critical is the context in which one finds oneself when managing an airway (see Chapter 6). The context is clearly different for each of these practitioner groups, although in practice there is cross-over, typically at the scene of an emergency airway. For this reason, airway management training programs for all disciplines must focus on the difficult and failed airway. Physicians, nurses, paramedics, emergency medical technicians (EMTs), and first responders often care for patients who are acutely ill or injured. In these situations, practitioners often find themselves in highly emotionally charged, urgent, high-stakes, high-risk environments.
Despite the multidisciplinary nature of airway management, the ultimate objective in training of all practitioners to be able to effectively manage airways and support gas exchange is the same. The practitioner must know what to do to manage the airway, when to do it, how to do it, when not to do certain things and how to get out of trouble when one finds oneself in difficulty. Each of these processes is potentially challenging. Proficient airway management requires one to master a host of anatomical, physiological, pharmacological, and technical aspects. The practitioner must know and understand the normal and pathological anatomy of the airway. These facts must then be integrated into an evaluation process that will lead to the selection of appropriate drugs and devices matching this particular setting. They must then be trained in the use of these drugs and devices. Critical to these decisions is developing the “sense” as to when might be the best time to intervene and then translate the intervention into real-life situations. A final complication is that frequently things do not go as planned and the practitioner must be able to rescue the situation (and the patient) if the initial plan fails.
Despite the development of new devices, strategies, and algorithms to predict, manage, and secure the difficult airway, morbidity and mortality associated with failed gas exchange and airway problems, such as difficult intubation or unrecognized failed intubation remain high. As emphasis has been focused on improving airway management, it has become apparent how difficult it is to teach airway management well, and ensure that the trainee has mastered those skills critical to routine airway instrumentation, as well as those required for difficult and failed airway situations. The problem seems to lay both in the area of adequate skills acquisition as well as in the transfer of these skills and strategies to daily clinical practice. Common methods for airway management training have historically included lecture/cognitive instruction mixed with hands-on sessions with simple intubating mannequins and occasional animal models, or structured curricula in physician training programs.2 However, since the publication of To Err is Human, health care professionals have looked to high-reliability industries, such as commercial aviation, for guidance on improving training as well as system safety.3 One of the most widely adopted aviation-derived approaches is simulation-based skills and team training.
Medical simulation has become increasingly popular over the last decade as a means for teaching a variety of skills to a broad spectrum of practitioners. However, has it been shown to be effective and does it change practice and improve outcomes? These are difficult measures to quantify given the lack of homogeneity of practitioner’s clinical practice.
Do we need evidence that simulation is effective when the reality is that it’s becoming less acceptable to perform procedures on patients when the practitioners have had little or no training with the required skills, have not been assessed for proficiency on the skill being employed, and have had no prior experience? The answer is obviously NO. The “see one,” “do one,” “teach one” method of training is not appropriate for high-risk but low-frequency events, such as cardiac or respiratory arrest and difficult or failed airway management.
Patients have become increasingly concerned that students, residents, and for that matter, fully trained practitioners, “practice” on them as they develop the required basic clinical skills or become skilled with new devices as they are introduced. With this change in attitude by patients, clinical medicine has become more focused on patient safety. This has helped to shift the many aspects of clinical skills training from the bedside to arenas where patients are not at risk and the learner is the focus of training. Educators have faced these challenges by restructuring curricula, developing small-group sessions and increasing self-directed/independent learning opportunities. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Medical simulation has been proposed as a tool to bridge this educational gap. In a meta-analysis conducted by Okuda et al.,4 simulation-based training has been demonstrated to lead to improvements in skills. This improved performance was translated into improved medical knowledge, improved performance of basic skills, improved confidence in performance of procedures, improved teamwork and communication performance, improved clinical performance, and improved performance during retesting at a later date. Fewer studies have demonstrated direct improvements in clinical outcomes, but evidence to this effect is slowly accumulating.5,6
Simulation training offers a controlled, safe, and reproducible environment which can be used to train and practice clinical interventions, especially for high-risk and low-frequency events. It has also been shown to be effective in acquiring clinical skills proficiency and improving performance and patient care in real clinical situations.7 But most importantly, it is through simulation that skills (cognitive as well as psychomotor) acquired in isolation can be translated into “lifelike” clinical settings. In light of the decrease in exposure to general anesthesia in obstetrics for cesarean delivery, there is mounting evidence that simulation may provide a suitable alternative to actual clinical experience in this unique situation of rapid sequence induction in the obstetric patient.8–10
Recently, simulation has been shown to not only improve performance of skilled tasks, but also reduce reaction time and increased adherence to protocols, in stressful situations with practitioners feeling more confident in their abilities to respond to high-risk but low-frequency events.11
Several studies have examined the effectiveness of airway management simulation training. There is a consensus that it improves performance.7,12,13 This has been supported in a recent review published in 2014.14 Retention of technical and decision-making skills has been shown to last for up to a year.9,11,12 Multiple sessions of moderate length, rather than single sessions of excessive length seem to provide better training experiences and retention of skills. Sessions of 75 to 90 minutes appear optimal.13
Moving forward, decisions regarding optimal use of high- and low-tech simulation in anesthesia training, together with teaching nontechnical skills in a cost-effective way need to be addressed.14
The potential benefits of simulation include:
no risk to patients
management of patients with rare medical conditions that every trainee needs to see
practice on rare but critical events—patients they may never see but need to learn to manage
participants can see the outcomes of their decisions and actions
participants can be allowed to make errors—let them “walk the plank”
identical scenarios can be presented to different clinicians or teams
team training—“crew resource management”
repetition and feedback to consolidate skills
Simulation has emerged as a key educational resource in areas where a combination of cognitive and technical factors combine to force the participant to decide the best course of action. The evidence from the literature suggests that simulation enhances performance and that performance enhancement is sustained.15
There is also evidence that simulation enhances development of airway management skills, reducing the need for actual live patient training.7,16 This is fortunate when considering the costs of such training, the scarcity of real humans to practice on, and the need to find a surrogate training model, particularly as it is felt that a major cause of high intubation failure rates by airway practitioners is inadequate training and skills maintenance.
Our conclusions support the concept that in-house workshops employing simulation technologies need to be conducted to keep the health care teams that manage airways effective and proficient.
Simulation can be a highly effective approach for the acquisition of knowledge, task and skills proficiency, decision making, and teamwork. It is especially effective in acquiring skills that require eye–hand coordination and ambidextrous maneuvers common to many airway management devices, such as bronchoscopy. This type of training also helps learners prepare to deal with unanticipated rare medical events, develop teamwork and communication skills, increases confidence, and improves performance. Once simulation has produced mastery of fundamental skills, it can expose trainees to difficult situations, abnormalities, and other problems. Advanced simulations can reinforce skills that have been previously learned. Consequently, simulation is not just for new trainees. It can be at least as useful for established practitioners who are constantly challenged to update their skills in response to rapid changes in clinical practice. Simulation offers the foundation for an interdisciplinary approach to education—equally appropriate for physicians, nurses, EMTs, therapists, technicians, phlebotomists, and other health professionals.
There are essentially three basic types of simulation environments.
(1) Specialized Simulation Center
For those interested in developing their own simulation programs, simulation training can often occur in a specialized simulation center. A simulation center provides a quiet, focused, safe environment where trainees can practice skills, be assessed either individually or as teams, and continue to train until proficiency is attained. However, most practitioners do not have access to such a center.
(2) In Situ Simulation Training
In recent years, a new arena for simulation training has emerged, “point-of-care” or what is most recently termed “in situ” training. In situ simulation has evolved as a particular form of simulation, distinct from simulation that is conducted in a simulation center. Patterson et al.17 have published an excellent review on in situ simulation, including the challenges and results.
In situ simulation does not replace simulation conducted in the simulation center. In fact, the objectives of training conducted in a simulation center are likely to be very different from the objectives of in situ simulation. Training based at a simulation center is often related to a curriculum or course and has objectives related to both technical and nontechnical proficiencies (e.g., basic suturing skills, central line placement, direct laryngoscopy, endoscopic intubation, communication, and teamwork). On the other hand, in situ simulation allows teams to review and reinforce their skills and to problem-solve in the clinical environment, while helping resolve workflow and system errors.18
In situ simulation occurs in the actual clinical environment with participants who are on-duty clinical practitioners during their actual work day. As an educational tool, it promotes experiential learning by training the health care provider in the actual environment in which the practitioner is expected to use these skills. Experiences in simulation labs may accomplish this to some degree, but in situ simulation, by definition, is more closely aligned with the actual “work” of the health care practitioner and is more likely to achieve success for certain training objectives. It provides a method to improve teamwork, team communication, and safety in high-risk areas. Given that the simulation occurs in the clinical environment, there are opportunities to identify hazards and deficiencies in the clinical systems, the environment, and the practitioner team.
For those institutions that are just beginning to develop simulation programs, in situ simulation offers an opportunity to begin to expose clinical personnel to simulation at considerable cost savings over a “bricks-and-mortar” center.
(3) Simulation Incorporated into Specialized Airway Management Training Programs Offered in a Variety of Locations
Examples are those courses offered at national meetings such as the American Society of Anesthesiologists and American College of Emergency Physicians (ACEP); and stand-alone courses such as Street Level Airway Management (SLAM), Airway Interventions and Management in Emergencies (AIME), and the Difficult Airway Courses (DAC).
It is clear from the educational literature that no single method of education (classroom lecture alone, case studies alone, skills labs alone) adequately teaches complex cognitive and technical skills, such as airway management. This is consistent with the experience of the authors over decades of education of health care practitioners at all levels. An instructional method that integrates didactic teaching, case studies, and skills development provides the most valuable educational experience. Simulation appears to be an educational technology that might just incorporate all of these methods into one coherent package.19