Training for the difficult airway – real life or simulation?

Karel explains need in prehospital medicine to be flexible
Karel explains need in prehospital medicine to be flexible

There is an old saying in anaesthetics : “In the predicted difficult airway, get the most experienced intubator to perform the procedure”

An eternal dilemma for clinical supervisors and educators, consultants/attendings in charge of junior doctors and trainees, is how to provide adequate training for management of the difficult airway ( predicted or unexpected).

Does simulation training prepare staff adequately? What role is there for allowing supervised practice on real patients expected to be a difficult airway?

To answer these questions, let us examine what is the current paradigm for training competency for the difficult airway : how does an emergency consultant, anaesthetist or intensivist achieve a base line competency in managing the predicted difficult airway?

Well, believe it or not there is no agreed standard curriculum. Each college in each country in each discipline has their own curriculum for managing the difficult airway. How is baseline competency assessed? Some espouse logbooks to track number of intubations, rapid sequence inductions etc. Some curricula recommend minimum supervised training terms of , say 6 months of elective anaesthesia etc. North American EM curricula recommend some anaesthesia terms but minimum time periods may be as low as 1 month.

But this is not really addressing the issue specifically. Just because you spend elective anaesthesia time in supervised teaching does not necessarily mean you will undertake difficult airway cases, predicted or not. In all likelihood the junior trainee will not be given exposure to manage a predicted difficult airway case in the OT/OR.

So what is the current paradigm? Basically, time and experience will hopefully allow the consultant/attending to gain enough practice in managing difficult airway cases. Problem is that we know that many may never gain experience in an actual emergency surgical airway for example, in their entire careers. How do we know that a newly graduated consultant /attending in EM, ICU or anaesthesia, is able to adequately manage a difficult airway? The frank answer , is that we do not know for sure!

Why not? Because we cannot adequately test it in the real world. How do we know the new anaesthetic consultant will be able to perform an emergency surgical airway if they have never done one? How do we know if the new EM consultant can perform an awake orotracheal intubation if that is needed, despite never having done one? The ICU consultant who has never done a paediatric RSI in training, how can they be sure that their adult based training can be used successfully in a predicted paediatric difficult airway like epiglottitis for example?

Now to be practical we make assumptions that base specialist training should deliver baseline competency for all curriculum requirements. Thats an assumption and extrapolation of many factors. For example, 6 months of anaesthesia term, will provide adequate practice and exposure for gaining competency in emergency airway management including surgical airway techniques. Big assumption.

Which returns us to the original dilemma. If a supervising consultant/attending has little or no real experience of difficult airway cases, how are they able to supervise and teach juniors/trainees and feel confident to allow their junior staff to practise on real cases?

And really is it ethical to allow an inexperienced provider to practice managing a clearly difficult airway case, even under supervision by someone who themselves have little or no experience of managing that difficult airway situation?

Lets try to use a hypothetical case to illustrate the issue better.

You are in the emergency department as a new consultant. its your first shift and a new rotation of junior residents/trainees. They dont know you and you dont know them. The ambulance brings in a road accident victim, a 4 yo child who has been run over. He has multiple injuries to head,chest, pelvis and limbs. He has obvious facial and mandible fractures with epistaxis and oral bleeding. Combative and crying, he is hypoxic and tachypnoeic.

The junior registrar who is allocated to the Airway role in the trauma resuscitation protocol, starts getting airway equipment ready. She asks your advice. What would you do? Allow her to continue setting up for airway management or suggest that yourself take over for this case?

Lets for arguments sake, say that the junior registrar has done 6 months of anaesthetics.

Who would allow her to proceed and manage a predicted difficult airway?

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