Best Practice & Research Clinical Anaesthesiology Vol. 19, No. 4, pp.

717732, 2005
doi:10.1016/j.bpa.2005.07.007 available online at http://www.sciencedirect.com

11 Education and training in airway management

Kai Goldmann*
Consultant Anaesthetist Department of Anaesthesia and Intensive Care Therapy, Airway Management Research and Training Centre, Philipps University Marburg, 35033 Marburg, Germany MD, DEAA

David Z. Ferson
Professor of Anaesthesia

MD

Department of Anesthesiology and Pain Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA

Despite the use of alternative training methods and efforts to structure training, it remains a challenge to ensure that every anaesthesia trainee gains sufcient experience in the use of core techniques of airway management. As less time is spent in the operating room during training, it becomes less likely that trainees will be exposed to an adequate number of challenging airway cases that enable them to practise advanced techniques of airway management under supervision. Nowadays the only way to overcome this decit in anaesthesia training is to prepare trainees as well as possible outside the operating room so that clinical training opportunities can be used most effectively when they arise. Sufcient training can only be ensured when the required equipment and time are provided. Therefore, particularly in the light of increasing economic pressures, it is necessary to address the responsibilities of everyone involved in the training process. Here, we critically review traditional and recent modalities of anaesthesia training, assess their value, and describe a multi-modal approach to airway management education. Key words: airway; anaesthesia; computer simulation; bre-optic intubation; laryngeal mask airway; teaching; training.

Today the discipline of anaesthesia comprises many aspects of perioperative medicine. As a consequence, anaesthesia training has become a very comprehensive challenge. In the light of the fact that nowadays less time is spent in the operating room during residency1, it becomes even more challenging to ensure adequate anaesthesia training that not only covers all aspects of perioperative medicine but also provides in depth

* Corresponding author. Tel.: C49 6421 2862516; Fax: C49 6421 2866996. E-mail addresses: kaigoldmann1@aol.com (K. Goldmann), dferson@mdanderson.org (D. Ferson).

1521-6896/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved.

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training in basic areas and techniques of anaesthesia practice. One such area of practice is airway management. Airway management has been considered one of the cornerstones of anaesthesia practice ever since the discipline emerged more than 100 years ago. Indeed, for a long time the anaesthetist was concerned mainly with taking care of the airway to ensure adequate oxygenation and ventilation during surgery. However, the clinical importance of airway management was not fully realized until the 1990s when the closed claims analysis of the American Society of Anesthesiologists (ASA) proved that adverse events associated with airway management were one of the leading causes of anaesthesia-related morbidity and mortality.2 Surprisingly, the data showed that in the majority of adverse events (75%) substandard care was involved, and that most of these events (70%) were considered preventable. As a consequence various national and international expert groups and societies have devoted much time to improving anaesthesia outcomes by setting standards for airway management and formulating guidelines for the management of unanticipated difcult airways.38 Although it is believed that the use of airway management guidelines can reduce the incidence of airway-related adverse events9, the individual patient with a difcult airway will always pose a challenge to the individual anaesthetist. Therefore, the care of each individual patient depends on the expertise of the anaesthetist, which is based on his/ her training, education, and familiarity with different airway devices, techniques, and algorithms. The structure of training at teaching hospitals determines the quality and quantity of training and therefore the airway management practice patterns of anaesthetists. This explains why airway management training and education is relevant to reducing anaesthesia-related morbidity and mortality.

PROBLEMS WITH AIRWAY MANAGEMENT TRAINING Until recently, airway management skills and knowledge were acquired on the job, haphazardly, whenever a training opportunity arose. During the course of a long and intense period of residency, most trainees were exposed to a sufcient number of challenging airway cases to enable them to practise advanced techniques of airway management under supervision and to become competent in airway management. For many years it was believed that this kind of training experience was sufcient to raise future generations of consultant anaesthetists. Taking into consideration the data from the ASA closed claims analysis and results of recent surveys on airway management patterns in various countries1013, it must be questioned whether this belief has ever been justied. Today, for various reasons, it seems even less likely that this traditional training approach can ensure that the majority of trainees acquire the necessary knowledge and skills in basic and advanced techniques of airway management. One of the most important reasons is that trainees spend less time in the operating room and therefore are exposed to fewer cases in general. Much time is instead spent on other aspects of training, such as pain management and intensive care medicine, or on non-clinical aspects of training such as the business aspects of health-care management. In addition, in Europe the hours of duty for residents have been reduced by the European Working Time Directive. Another reason that the traditional approach to anaesthesia training may be lacking relates to current changes in anaesthesia practice. Increased use of

Education and training in airway management 719

regional anaesthesia techniques14 and supraglottic airway devices15 has greatly reduced trainees exposure to endotracheal intubation (ETI) and facemask (FM) ventilation, the cornerstones of airway management. Traditionally, trainees have become competent in these basic techniques of airway management by performing them many thousands of times. This is no longer the case.

AIRWAY MANAGEMENT TRAINING REQUIREMENTS AND GOALS It is imperative that anaesthesia training as a wholeand airway management training in particularare reorganized and become more structured. Although the primary responsibility for learning lies with the trainee, the departmental leadership and the institutional authorities are responsible for providing the required infrastructure and organization to facilitate training and education.16 Todays risk management requirements make it mandatory for every anaesthesia department to set minimal standards of airway management, to ensure that every trainee receives a structured training to meet these minimal standards, and to provide proof thereof.16,17 To utilize the entire training period most effectively, it is important to dene overall training goals and to identify the point of time in the residency when certain aspects of training should be incorporated into the daily schedule to achieve these goals. Todays airway management training requirements are manifold; however, from the authors point of view some overall requirements can be formulated: 1. the patients safety is the highest priority, therefore the patient must be protected from the total novice; 2. basic airway management knowledge and skills must be taught continually throughout the entire residency; 3. advanced airway management techniques should be taught as soon as possible in the residency; 4. new techniques and devicesin particular various new supraglottic airway devicesshould be taught selectively after the trainee has acquired basic airway management techniques; 5. in this context it is necessary to teach not only when and how to use various devices but also when not to use those devices; 6. decision-making, i.e. the integration of different skills and techniques and the use of a difcult airway algorithm in complex clinical situations of difcult airway managementshould be taught as soon as possible; 7. senior trainees need to be taught how to teach airway management skills and techniques using all current training modalities so that they will become competent in educating future residents. To meet these requirements there must be a syllabus of core knowledge and skills and a denition of basic and advanced airway management techniques (Tables 1 and 2). Anything considered to be a core knowledge or skill must be taught and examined.17,18 As a consequence, all trainees will gain sufcient training experience in these core techniques.

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Table 1. Basic airway management techniques. Facemask ventilation and simple manoeuvres to open the airway Laryngeal mask airway usage Oral endotracheal intubation using direct laryngoscopy Use of simple manoeuvres (OELM, BURP) to improve direct laryngoscopy Use of stylet and gum elastic bougie Rapid sequence induction Intubating laryngeal mask airway usage Fibre-optic intubation via conduit like oropharyngeal airway or laryngeal mask Percutaneous cricothyrotomy

OELM, optimal external laryngeal manipulation; BURP, backward upward rightward pressure.

ORGANIZATION AND TOOLS OF AIRWAY MANAGEMENT TRAINING Organization of airway management training in the past Traditionally, training in airway management consisted of teaching the three main techniques of airway management in a stepwise fashion. After a theoretical introduction, much emphasis was put on practising FM ventilation and easy manoeuvres to open the upper airway before trainees were allowed to progress to the next step. Once they had shown adequate FM ventilation skills, they were introduced to techniques of direct laryngoscopy (DL) and ETI. Both of these basic techniques of airway management were then practised continually throughout the entire period of anaesthesia training. In general, bre-optic intubation (FOI) skills were practised towards the end of the residency, often leaving future consultants with insufcient experience in FOI.10,11,19 In many departments other techniques of airway managementfor instance emergency cricothyrotomy (CCT)were hardly practised at all during residency, mainly because of the lack of good, affordable commercial manikins or competent instructors.20 Organization of airway management training today Today, there are many more than three core techniques of airway management in which trainees need to gain prociency. Teaching a larger number of airway management techniques adequately in a shorter period of time using a traditional stepwise training approach seems virtual impossible. Although certain knowledge and skills are necessary before more complex skills can be acquired, there is no good evidence to support
Table 2. Advanced airway management techniques. Nasal endotracheal intubation Use of alternative blades Use of tube exchange catheters Awake bre-optic intubation Elective transtracheal jet ventilation Placement of double lumen endotracheal tube

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the organization of training in a stepwise fashion. For example, laryngeal mask airway (LMA) use, FOI, and CCT can be taught effectively when other basic techniques of airway management have not been learned. Indeed, Cole and colleagues were able to show that novices can learn FOI as well as DL right at the beginning of their residency.21 Considering the central role of the LMA, FOI, and CCT in algorithms of difcult airway management4,8,22, all of these techniques should be taught right from the beginning of the residency. There is no scientic justication for waiting until a later stage of residency. Thus, a multi-modal training approach using all available training modalities should be applied to teaching all basic airway management techniques from the very beginning of residency. Basic knowledge and clinical skills block rotation There is good evidence to support the teaching of specialized skills such as airway management skills in block rotations.20,2325 We believe that it is best to organize 1 week of block education right at the beginning of the residency to provide trainees with the theoretical knowledge and some practical skills. Ideally, trainees will have unrestricted access to a skill room that contains educational literature and training tools such as models, manikins, and computers. Most of the trainees will have had an introduction to basic airway management techniques such as FM ventilation and ETI as students during their advanced cardiac life support courses. However, this week of block education should include lectures and tutorials covering the theoretical background of airway management, an introduction to the use of audiovisual selfeducation tools such as DVDs and CD ROMs, and supervised practice of basic airway management techniques using manikins. It is advisable to follow a standard sequence when teaching a practical skill. After explaining the theoretical background, the teacher should demonstrate the procedure in real-time using a model or manikin. This is followed by step-by-step demonstration and explanation.26 Usually, it is best to break down the procedure into no more than four or ve steps. The trainees can then practise the individual steps in the same model or manikin under supervision. After this initial phase, the trainees will be allowed to practise the procedure on their own. Once the trainees have been tested and have shown sufcient competence in particular skills, they will be allowed to practise those skills in the operating room on surgical patients.26,27 This clinical training should happen every day throughout the week of block education. Mixing clinical training and non-clinical training helps to transfer the knowledge and skills learned outside the operating room into clinical practice. Usually, the amount of clinical training in the operating room increases throughout the week of block training. Of course, only techniques that are used regularly and considered appropriate for a particular patient can be used for training purposes without obtaining specic consent from the patient. If teaching is the main reason for performing a non-routine technique, informed consent should be obtained.28 Clinical training is best organized with one consultant taking care of one trainee and acting as his/her tutor throughout the initial week of training. Working with different consultants at this stage would be confusing rather than helpful; however, once the trainee has progressed and consolidated his/her experience, it becomes of great value to see other ways of doing certain procedures to broaden the experience.

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The value of difcult airway play-acting scenarios For a long time, education in airway management has been focused mainly on teaching technical skills. However, mastering a difcult clinical situation requires much more than just performing the steps of a technical procedure. Other so-called non-technical skills are required to integrate medical knowledge, technical skills, additional procedures, and other team members. The necessity of teaching non-technical skills in anaesthesia is increasingly being recognized.29 A simple way of teaching some of these skills is to discuss what-if scenarios with trainees whenever possible. From the earliest stage of training onwards, it is advisable to include play-acting scenarios and discussion of common difcult airway management situations to foster decision-making in complex clinical situations. These scenarios should happen in small groups of 34 trainees and should include cases of difcult DL, difcult FM ventilation, failed DL, failed FM ventilation, an obstructed airway, rapid sequence induction, failed rapid sequence induction, awake ETI, and difcult extubation. Much emphasis should be put on understanding and applying a difcult airway algorithm. Simulators are best for practising and testing clinical competence in complex clinical scenarios;30,31 however, simple manikins can be used for the same purpose.32 Once these scenarios have been practised in a simulator or on a manikin, the trainee can perform supervised mock difcult airway scenarios on elective cases in the operating room. Because difcult airways are uncommon and the total number of cases that residents are involved in nowadays is decreasing, it is important to use as many normal elective cases as possible for these what-if scenarios of difcult airway management to compensate for the lack of true clinical experience. Documenting and testing clinical competence Throughout the entire training process it is important to test and document the trainees clinical competence to nd areas of weakness and to reinforce good performance. Testing can be done anywhere at any time, outside the operating room using simulators or manikins or inside the operating room during a routine anaesthesia procedure.16 It should be mandatory for the trainees to document in a logbook the theoretical knowledge and clinical experience they have gained in all basic and advanced techniques of airway management so that they can give proof of the number of times they have performed a particular technique.16 In general, for most techniques 1020 times is considered adequate to gain familiarity with the technique and to allow the trainee to continue to gain further experience through self-directed teaching.23,3336 It also should be mandatory for the teachers to document the performance of the trainees whenever clinical competence is tested, using the same logbook. In this way it will be possible to monitor the trainees progress throughout the residency and to give proof of sufcient education and training in airway management. Clinical training Hands-on training in the operating room will continue to be the most important training modality for anaesthesia residents. Observation of both parties, the trainee and the trainer, has always played an important role in teaching technical skills. However, in the past, observation during airway management was often limited to the visible outer

Education and training in airway management 723

aspects of the airway and their corresponding management. The inability to see the inner aspects of the airwayi.e. the view of the larynxand their corresponding management, particularly when airway management was difcult, was frustrating for observers. Today, modern airway management devices are equipped with video-optical systems that can be used very effectively to overcome this inherent problem of airway management. Video-laryngoscopes37,38 and closed-circuit bre-optic intubation systems27 are very powerful teaching tools. During the initial phase of training they can be used by the teacher to demonstrate a procedure like direct or bre-optic laryngoscopy and the consequences of common problems and mistakes. Thereafter, they enable the teacher to follow the trainee through a procedure and give him/her specic advice. This type of supervision becomes particularly valuable when airway management is difcult, enabling the teacher to allow the trainee to carry on instead of taking over the procedure prematurely to avoid any damage to the patient. Therefore, the use of video-optical equipment helps to improve patient safety in addition to providing genuine value as training tools. Most newer devices also allow one to videotape or to store digital information of the procedure so that trainees can review their own performance and supervisors can provide feedback to them. For all of these reasons we strongly recommend the use of video-laryngoscopes and closed-circuit bre-optic intubation systems not only for difcult cases of airway management but also for everyday education and training in airway management using routine cases. Alternative non-clinical training modalities Today there are many methods of airway management training available outside the operating room (Table 3). Each of these methods has its own limitations, and nothing can substitute for real hands-on practice. However, each has something to offer, and together they can be used to overcome the current difculties in providing trainees with sufcient comprehensive clinical training in airway management. Simple bench models Simple bench models have been used for a long time to enable trainees to acquire some dexterity with airway devices, in particular with the bre-optic bronchoscope and CCT sets. Despite their limitations in mimicking human anatomy, these models are valuable for familiarizing trainees with a device and providing them with some baseline dexterity.26,39 Naik and colleagues even showed that residents who practised FOI using a simple bench model performed better in patients than those who had prepared with didactic training only.40 This indicates that simple bench models can contribute to the overall goal of protecting patients from the total novice. Therefore, the authors
Table 3. Alternative training methods. Simple bench models Simple manikins Human cadavers Animals Virtual reality simulators High-delity full-scale simulators

724 K. Goldmann and D. Z. Ferson

strongly recommend the use of simple bench models at an early stage of training, as most trainees benet only marginally from simple bench models once they have gained their rst clinical experience. Manikins Simple manikins have been used for a long time in various elds of medical training.4143 They differ from simple bench models in that they more closely imitate human anatomy. Many commercial manikins are available for airway management training, ranging from isolated heads and necks to whole-body manikins. They can be used for basic ETI, LMA placement, CCT, or FOI training. To teach all the airway management techniques mentioned in the difcult airway algorithms it is necessary to have more than one type of manikin, because most do not allow for adequate training in all techniques.44 Despite their limited realism, the value of manikins for basic skills training has been shown in many studies.26,43,45 It is possible to improve the speed and success of various airway management techniques in the patient through repeated manikin practice.27,34 Once the trainee has acquired enough clinical experience to proceed to self-directed clinical training, simple manikins start to lose some of their value. Newer computerized manikins can give feedback and can be used to simulate simple airway management scenarios, thereby offering some degree of interaction and a more comprehensive training experience. Therefore, most manikins have the greatest value when used for basic skill practice at an early stage of training; thereafter, they remain useful for repeated practice of airway management techniques such as CCT that are rarely used in routine clinical practice. Human cadavers Human cadavers have always been used for training in medicine. There is some evidence that airway management techniques can be practised in human cadavers as well as in paralysed patients;46,47 however, there are no good data showing that such practice leads to improved outcomes in patients. Today, the use of cadavers for training is somewhat controversial. Advocates argue that a dead human body comes closest to a live patient and therefore offers a realistic training opportunity, to the benet of future patients. Others argue that this kind of training is no longer necessary considering the range of modern training modalities available. As with other training modalities, cadaver training has its own limitations. However, in the authors experience, fresh human cadavers can provide a more realistic training experience than manikins for most noninvasive and some invasive airway management techniques. In contrast to manikins, human cadavers present real human anatomy and tissue. FOI and bronchoscopy training in fresh cadavers, for example, has something to offer to the trainees48, namely that the cadaver anatomy is new for them and quite a contrast from the departmental manikins they have been using throughout their residency. Most trainees appreciate training using cadavers as a link between training using manikins and training using patients and nd it useful for their overall training experience. However, when using human cadavers for training purposes, two very important general principles should be followed. Consent must always be obtained, and the human body must be treated with respect and in accordance with the obtained consent.49 Animals Various species of animals have been used in anaesthesia and anaesthesia-related disciplines for teaching practical skills of airway management.5053 The advantage of

Education and training in airway management 725

Table 4. Invasive anaesthetic techniques practised in animals. Fibre-optic intubation and bronchoscopy Retrograde intubation Percutaneous tracheostomy Cannula cricothyrotomy Chest tube placement Peripheral nerve blocks and catheter placement Neuroaxial blocks and catheter placement Intra-osseous needle placement Arterial line placement

using animals is that potentially harmful procedures can be learned in a biological system of comparable anatomy capable of displaying physiological responses without putting patients at risk. Animals can be used both to practise procedures5052 and to simulate scenarios.53 As part of a training programme their use can improve patient care.53 One of the most important differences between the use of animals and manikins is that animal tissue, secretions and blood are much more similar to human tissue, secretions and blood than is plastic, which adds an important dimension of reality. This is particularly important when invasive procedures are practised. Animal workshops covering various elds of anaesthesia practice are routinely conducted at scientic meetings (e.g. Society of Airway Management, European Society of Regional Anaesthesia and Pain Therapy) and are offered by some academic institutions (e.g. the Department of Anaesthesia at Philipps University, Germany). It is debatable whether an animals life should be sacriced for the sake of practising LMA placement or ETI. However, at the authors institution (K.G.) a porcine model is used to teach residents a whole range of invasive procedures (Table 4). Non-invasive procedures such as LMA placement and ETI can be practised in the same workshop, so that each animal workshop is used as effectively as possible. As with animal studies, it is important to obtain animal welfare commission approval and to treat the animal according to current principles of welfare for animals used for experimental and other scientic purposes. Virtual reality airway simulators Recently, virtual reality partial task simulators (VRSs), a new generation of advanced technology training tools, have been developed for various medical procedures. For airway management training, a bronchoscopy training device is available that can be used for FOI and bronchoscopy training.54 This VRS can produce a training environment that closely resembles a clinical setting. The VRS bronchoscope feels like a real bronchoscope and can be steered in the same way. The interface device is capable of tracking the motions of the bronchoscope tip control lever and mimicking the forces and resistances felt during clinical bronchoscopy. The monitor displays realistic computer-generated anatomical images that correlate precisely with the motions of the bronchoscope and its expected anatomical position in the respiratory tract. In addition, the virtual patient is capable of displaying realistic physiological responses. For example, hitting the mucous membranes can cause bleeding, and omitting local anaesthetics causes the patient to cough, simulating the motions of the respiratory tract that one experiences in a live patient. The VRS computer records various data related to the performance of the bronchoscopy that can be used for

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analysis of performance and for teaching purposes. Training using a VRS has been shown to be more effective than didactic teaching and manikin practice only for the acquisition of basic FOI skills, which leads to higher success rates in clinical practice for novices learning FOI skills.54,55 From the authors experience, one very important advantage of the modern VRS over traditional manikins is that the computer software can provide a large number of ever-changing realistic tasks. This makes these tools very attractive to trainees over a long-time, whereas manikins start to lose their attraction as soon as the users becomes familiar with them. High-delity full-scale simulators Simulation has been used successfully for a long-time in the aviation industry56,57, and its role in training health-care providers has been increasing in the past decade.5860 It has been shown that full-scale simulator (FSS) training can improve the performance of anaesthetists in emergencies;60 however, an improvement in morbidity and mortality rates has not yet been shown. FSS training can facilitate a comprehensive learning of cognitive, psychomotor, and effective skills61, with the unique advantage of providing whole-task training. Simulator scenarios can be used to teach a single individual or a group of individuals, adding the opportunity to teach human crisis team resource management (i.e. interactive team performance in complex situations). Modern FSS simulators with advanced computer software allow for the creation of endless clinical scenarios with a high degree of reality, making FSS a training tool that does not lose its appeal for users who have used it many times. The ability to store a large quantity of technical data in conjunction with closed-circuit camera videotaping gives the participants and trainers the unique opportunity to see and analyse performances in real-time and to give feedback, thereby making FSS a very powerful tool for changing the participants behaviour. All of these aspects of FSS make it an ideal training tool for airway management, an area of anaesthesia practice that requires a highly coordinated team approach and well-prepared clinicians, not only in routine practice but in particular when rare serious adverse events occur.

STRATEGIES FOR CREATING A MULTI-MODAL AIRWAY MANAGEMENT TRAINING APPROACH IN A BUSY CLINICAL DEPARTMENT Changes in many European health systems and legislation have affected anaesthesia training. For example, the European Working Time Directive affects the amount of clinical training experience that residents can gain, as mentioned earlier. The economic pressures to use the operating room more efciently has also had an impact on the ability to train residents. The requirement to minimize anaesthesia change over time from one case to the next has led in some placesincluding one of the authors institutions (K.G.)to the consequence that, whenever possible, consultants induce anaesthesia in the next case in a separate induction room while the trainees are still taking care of the preceding case. This has particular relevance for the clinical training of airway management skills because most of the time difcult airways present during induction of anaesthesia. In the light of these restraints it becomes even more important to organize airway management training in the form of block rotations to ensure the adequate education of the trainees. Without dedicated blocks of education and training, it seems virtually impossible to ensure that time resources are dedicated to teaching despite the economic pressures put on daily routine clinical practice.

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Advanced clinical skills block rotation and further airway management training After the initial week of block education and several weeks of clinical experience, trainees should receive another block of clinical training with a focus on teaching advanced airway management skills. Certain techniques of airway management and difcult airway management strategies need to be addressed specically. Ideally, this happens in a place where difcult airway cases are more common, such as the maxillofacial or ear, nose and throat department, but it can happen anywhere. During this week of advanced training it is crucial that both the trainee and a consultant (ideally one with a focus on airway management) are supernumerary so that dedicated training can be ensured. For most departments, it is probably impossible to train a whole set of new trainees simultaneously in this way. Therefore, some of the trainees will receive this kind of block training earlier and others later. Ideally, this second block rotation happens at an early stage of residency. The clinical experience must then continue afterwards so that the seeds sown during the blocks of airway management training will grow and ourish. This makes it very important to use any available clinical training opportunity during the remaining years of the residency. The use of non-clinical training modalities also must continue throughout the entire residency. The big advantage of non-clinical training modalities is that they can be utilized at any time independently of clinical cases and economic restraints. An hour of skill room training can be tted into any working day when clinical duties nish early, and even simulator training can be organized in the afternoon after routine clinical work is completed. Often trainees do not receive an adequate amount of appropriate nonclinical training during their working hours. At one of the authors institution (K.G.), FSS training is usually organized so that one group of residents participates in a simulator training session in the morning and then takes over the clinical duties of the other group of trainees so that they can receive simulator training in the afternoon. Often, this requires the trainees to stay longer than their regular hours of duty. Training using a porcine model usually happens once a month in the afternoon, also after the clinical duties have been completed. Our own experience shows that residents value the opportunity to be trained very much and do not mind spending unpaid extra hours in training, and neither do the consultants who supervise. Because anaesthetic technicians play an important role in airway management not only during routine practice but also when airway management is difcult, they routinely take part in the simulation training sessions using FSS and animal models. Continuous medical education and training in airway management Considering the ever-increasing number of airway management devices and techniques and the decreasing clinical experience gained during residency, it is clear that not every skill or technique can be learned during residency. There is no doubt that training must continue for specialists.8,9 Not only should junior consultants consolidate their skills with certain techniques and broaden their repertoire of airway management skills, but also there is some evidence that review and retraining should happen on approximately an annual basis to maintain knowledge and skills that otherwise deteriorate.62 So far, there have been no studies on the usefulness of various training modalities for the retention of airway management skills. In clinical practice, self-directed clinical training plays by far the most important role for consultants in continuing their training in airway

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management. However, without any kind of supervision or feedback it would be impossible for them to improve their clinical or non-clinical airway management patterns. Simulation can be used effectively to give feedback and to inuence participant behaviour. It is the authors belief that regular simulator training should be considered mandatory for anaesthesia consultants, as it is for aircraft pilots. Commercial airway courses and workshops held at anaesthesia departments or at scientic meetings are another opportunity to learn new techniques, to see new ways of performing certain techniques, and to improve skill levels in techniques of airway management. The content and quality of these courses can vary; however, most are well organized and run by airway management enthusiasts. Overall, it is the individual consultants and his/her departments responsibility to keep knowledge and skills up to date and to ensure familiarity with newly introduced devices and techniques of airway management. Costs of training: the medico-legal responsibility of authorities Under the current economic constraints of heath care, minimizing the costs of services plays an ever-increasing role. The costs of equipment and time of clinicians allocated to training have come to the attention of hospital administrations. There is an imminent risk that teaching budgets will be cut and that time resources allocated to education and teaching will be re-allocated to provide billable clinical service. However, it is within the medico-legal responsibility of the educational authorities and the teaching hospital administrations to ensure adequate training if teaching hospitals accept the responsibility of educating future consultants. Most of the trainees and consultants involved are willing to spend extra hours teaching and training without claiming any extra payment. Considering this, it should be possible to supply at least a basic selection of audiovisual training material, training tools, simple manikins, and simulators, and to allocate the time resources required. The reality at many institutions, however, is that this is not always the case. Authorities and clinical directors need to understand that the cost of the training tools described appears quite low and affordable in contrast to the cost of a single malpractice claim resulting from airway-related morbidity due to an under-qualied health-care provider.

SUMMARY Education and training will always be the foundations of acquisition and retention of technical and non-technical skills in medicine. Although many studies have shown the ability of various training modalities to improve performance in many airway management techniques, there are no good comprehensive studies investigating the value of different training approaches in airway management to reduce anaesthesiarelated morbidity and mortality. There have been important advances in airway management in the past decade, mainly because of steady research and technical advances resulting in evidence-based standards and guidelines for airway management and the increased use of highly sophisticated airway devices. Currently, however, the provision of adequate comprehensive training in airway management is at risk. If we do not nd a way to ensure appropriate structured training using all currently available training modalities,

Education and training in airway management 729

these advances will be at risk, and airway-associated problems will continue to be among the leading causes of anaesthetic morbidity and mortality. It must be a focus of future research to investigate the impact of structured training approaches on airwayrelated morbidity and mortality. Only this can provide the evidence required to ensure that sufcient nancial resources will be allocated to education and training in the future. Practice points address responsibilities of trainees, trainers, administration and authorities dene airway management core knowledge and core skills organize training in block rotations dene overall airway management training requirements and goals use a multi-modal training approach to teach all core skills simultaneously right from the beginning use non-clinical training modalities to prepare trainees as well as possible for clinical training opportunities focus on continuous teaching of non-technical skills focus on understanding and application of a difcult airway algorithm ensure documentation and testing of clinical competence ensure dedicated training time resources for both trainees and trainers resist re-allocation of training time resources to provide clinical services

Research agenda Randomized controlled trails are required to: establish the value of a multi-modal teaching approach versus a traditional stepwise teaching approach establish the value of a combination of various teaching tools versus single teaching tools determine the minimal amount of clinical training required to ensure a sufcient training in airway management determine the value of non-clinical training modalities to compensate for a lack of clinical training determine the inuence of the increasing economic pressures on airway management training primary outcome parameters of studies on airway management training must be airway management-related morbidity and mortality multi-centre studies are required to provide sufcient power for studies where large numbers of cases are required

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