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

BRITISH JOURNAL OF ANAESTHESIA

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 one- third 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 res- piratory 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 tech- niques 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 impera- tive 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 compro- mised 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 spe- cific 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 priv- ileged few may result in dilution of training opportu- nities 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 air- way 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 coor- dinate the training of airway management. A recent survey of tutors of the Royal College of Anaesthetists noted that only 37% of UK departments offered for- mal 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, train- ing objectives and assessments.10 Each specialty module contains some elements pertinent to the air- way, 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 elec- tronic 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 cri- sis. 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 work- ing at the coal-face. Those who have forged the new postgraduate education strategy have failed to recog-

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nize the special needs of trainees in the artisan spe- cialties of surgery and anaesthesia. Facts and theory can be learned from books and in the classroom. They can be reiterated when required for examination, lec- ture 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 stu- dents cannot be underestimated.14 Good anaesthesia teachers combine enthusiasm, willingness to teach and an inquiry approach.15 The worth of such clini- cians 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 pro- fession, 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 anaes- thetic 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 the- ory and practice of a variety of respiratory-related procedures and associated equipment. It will include the basic skills of airway assessment, mask ventila- tion, tracheal intubation and airway decision making, in addition to the more advanced techniques of fibre- optic intubation and percutaneous tracheostomy. One or two consultants with the appropriate exper- tise 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

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 fundamen- tal. 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 train- ing is entirely different from resuscitation training and must be kept separate. However, as with CPR training, the use of manikins is now essential for sev- eral 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 intuba- tion 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 algo- rithm approved by the American Society of Anesthesiologists.18 However, it is important that the complex-looking posters that adorn many anaes- thetic 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, consider- able preparation should have taken place. Complex skills are best learned gradually, by dividing the com- plete process into several simpler tasks.20 For fibre- optic intubation, there are numerous opportunities to learn outside the operating theatre. Attendance at diagnostic bronchoscopy lists21 and ENT outpatients22

Editorial I 307

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 per- form 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 tech- niques.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 sys- tem 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 invest- ment 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 equip- ment 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 air- way management training.

R. A. MASON Department of Anaesthesia

Swansea NHS Trust Singleton Hospital

Swansea SA2 8QA

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