Training in Airway Management
Mark Lischner
James Snyder
This chapter simplifies alternatives to airway training in terms of polar opposites, neither of which exists in pure form, to provide a framework for understanding the value of specific concepts and maneuvers.
In experience-based training, skill is acquired primarily through practice with elective surgery patients, initially with expert supervision, then with support immediately available for routine cases as skill develops. Because risk is low, multiple laryngoscopies are acceptable and independence and efficiency can be priorities. Call for assistance is a sign of failure, independence a sign of personal skill.
After basic skills are acquired, practiced use of endotracheal tube introducers (ETI) in simulated epiglottis-only cases is now considered fundamental to airway management. However, low learning trajectories suggest substantial dependence on experience. For example, anesthesiology residents required three or more attempts to intubate in 14.5% of emergency cases in their first clinical year, 10.4% in their second year, and 9% in their third, compared with 6.3% by attending staff (Fig. 14-1).1
In contrast to experience-based training, careful preparation for “first pass success” has been emphasized by Levitan and others to address different clinical and training program needs.4,5,6 The focus is on optimal care of critically ill patients and achieving highest possible success rate with least patient risk. Ideally, the end-product is a smoothly coordinated sequence of maneuvers that achieves optimal glottic exposure and enables even novices first pass success despite unpredicted difficulty. The educational structure that leads to firstpass success is related to reverse engineering to understand individual skills and provision of support during intubation that allows exploration and practice of each skill independently, then in combination with other skills. Every case is presumed an unpredicted difficult intubation, justifying planned incorporation of passersby as assistants and emphasis on navigational tools to ensure the objective, and application of every support until exposure is optimal rather than adequate. Skills are acquired via “dry lab” simulation and cadaver training when available. In every case, trainees are encouraged to prepare for advanced techniques in case of unpredicted difficulty and to maximize success despite their limited experience.
Shorter learning curves have been reported by emergency medicine (EM) and critical care medicine (CCM) training programs that focused on patients at greater risk. In programs designed to manage airways of critically ill patients, performance after 6 months experience was comparable to critical care attendings with an anesthesiology background,7 and EM resident performance in postgraduate years 3 and 4 were comparable to anesthesiology residents in postgraduate years 2 to 4.8 In a program where total experience may be less than 200 cases, EM resident intubation success rate in a trauma emergency room was 97%.9
At the University of Pittsburgh Medical Center about half of the more than 20 physicians who start CCM fellowship each year are airway novices. Dispersion of responsibility throughout the hospital requires novices with minimal training opportunity unavoidably to serve as first responders at emergent events. Despite excellent support by operating room (OR) anesthesiology attending staff, program requirements entail clinical responsibility before training described above for EM programs can be provided. Although CCM attendings are in-house and attend codes 24/7, proximity and multiple simultaneous events result in potential for unsupervised novices being the first responders to codes. Advance training using cadavers has been restructured to assertively apply advanced airway skills, including first pass success as championed by Levitan.4,5,6 Novice CCM fellows self-reported success in 85% (78% first pass) of their first 99 intubations of critically ill patients in 2007 (10 fellows, mean 7.6, range 1 to 13).10 Data collection was not quality-controlled well in this pilot study; subsequent quality-controlled data are now being analyzed.
Factors that favor accelerated training in airway care and techniques that appear to accelerate the success rate and/or patient safety are summarized in Tables 14-1 and 14-2.
Although there is need for increased and accelerated training and the number of cases is declining, several factors may weigh against incorporation of the first pass approach to direct laryngoscopy (DL) (Table 14-2).
 FIGURE 14-1 Intubation: conventional learning curves for intubation by DL. The solid and dashed-line curves indicate selfreported success rate for anesthesiology trainees during OR training in two centers.2,3 Solid: Konrad et al.2 Dashed: Mulcaster et al.3 Low X: Novice paramedic trainee success rate in OR after conventional orientation. High X: Novice paramedic trainee success rate after similar training plus advance viewing of operator-view videos.4 Circle: Novice CCM fellows after advance video of operator view and cadaver lab.5 |
Table 14-1 Factors that Favor Accelerated Training in BMV and DL | ||
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