|Year : 2019 | Volume
| Issue : 3 | Page : 326-334
Advanced airway training in the UK: A national survey of senior anesthetic trainees
Adam J Boulton1, Sunita R Balla2, Aleksandra Nowicka2, Thomas M Loka3, Cyprian Mendonca2
1 University of Warwick, Medical School Building, Coventry, CV4 7AJ; University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
2 University Hospitals Coventry and Warwickshire NHS Trust, Coventry, CV2 2DX, UK
3 Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, BS1 3NU, UK
|Date of Web Publication||3-Sep-2019|
Dr. Adam J Boulton
University of Warwick, Medical School Building, Coventry, CV4 7AJ
Source of Support: None, Conflict of Interest: None
Background and Aims: High-quality training in advanced airway skills is imperative to ensure safe anesthetic care and develop future airway specialists. Modern airway management skills are continually evolving in response to advancing technology and developing research. Therefore, it is of concern that training provisions and trainee competencies remain current and effective.
Material and Methods: A survey questionnaire based on the airway competencies described in the Royal College of Anaesthetists' curriculum and Difficult Airway Society guidelines was posted to all United Kingdom (UK) National Health Service hospitals to be completed by the most senior anesthetic trainee (ST 5–7, resident).
Results: A total of 149 responses were analyzed from 237 hospitals with eligible anesthetic trainees (response rate 63%), including 53 (36%) and 39 (26%) respondents who had completed higher and advanced level airway training respectively. Although clinical experience with videolaryngoscopy was satisfactory, poor confidence and familiarity was identified with awake fiberoptic intubation, high frequency jet ventilation, at risk extubation techniques, and airway ultrasound assessment. Only 26 (17%) respondents had access to an airway skills room or had regular airway emergency training with multidisciplinary theater team participation. Reported barriers to training included lack of training lists, dedicated teaching time, experienced trainers, and availability of equipment.
Conclusions: This national survey identified numerous deficiencies in airway competencies and training amongst senior anesthetic trainees (residents) in the UK. Restructuring of the airway training program and improvements in access to training facilities are essential to ensure effective airway training and the capability to produce future airway specialists.
Keywords: Difficult airway algorithm, nasal fiberoptic intubation, practice standards: definition, training
|How to cite this article:|
Boulton AJ, Balla SR, Nowicka A, Loka TM, Mendonca C. Advanced airway training in the UK: A national survey of senior anesthetic trainees. J Anaesthesiol Clin Pharmacol 2019;35:326-34
|How to cite this URL:|
Boulton AJ, Balla SR, Nowicka A, Loka TM, Mendonca C. Advanced airway training in the UK: A national survey of senior anesthetic trainees. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2021 Jun 14];35:326-34. Available from: https://www.joacp.org/text.asp?2019/35/3/326/265922
| Introduction|| |
The ability to manage an airway reliably and safely is an absolute necessity for all anesthetic, critical care, and emergency care physicians.,, Failure to manage the anesthetized patient's airway appropriately can result in a can't intubate, can't oxygenate (CICO) scenario. Although rare, this can result in hypoxic brain damage and death. The Fourth National Audit Project of the Royal College of Anesthetists (NAP4) and the Difficult Airway Society (DAS) have identified lack of training in advanced airway skills such as awake fiberoptic intubation (FOI) as a contributing factor to major complications in airway management., The Royal College of Anesthetists (RCoA) defines the curriculum for trainee anesthetists and stipulates airway skills that should be achieved during basic, intermediate, higher, and advanced level training. Furthermore, the DAS guidelines for management of unanticipated difficult intubation and tracheal extubation recommend training and competence in skills including videolaryngoscopy, fiberoptic guided intubation via a supraglottic airway device (SAD), surgical cricothyroidotomy, and advanced extubation techniques., There are a wide range of necessary technical and nontechnical competencies in airway management., Structured training in advanced airway management skills is therefore of high importance.
Awake FOI is an important technical skill, but for several reasons has become less commonly practiced.,, In addition, training in the clinical environment has been further restricted due to changes in working patterns and service provision demands.,, Advancing technology has introduced new techniques and expected competencies.,, Appropriate training and sufficient practice with new equipment and techniques is imperative to allow safe and effective application. A previous United Kingdom (UK) national survey evaluated the provision of airway training from a trainer's perspective and found a wide variation in the content and delivery of out of theater airway workshops. Since then changes to the structure of airway training including collaboration with surgical specialties, assisting with procedures such as tracheostomies, and multidisciplinary training has been suggested.,
We aimed to determine whether UK senior anesthetists in training are able to achieve necessary competencies in airway management skills as specified in the RCoA curriculum and DAS guidelines, determine their access to training facilities, and identify barriers to training. We therefore surveyed senior anesthetic trainees in the UK to assess their training and competencies in advanced airway skills.
| Material and Methods|| |
Formal UK Health Research Authority approval was not required for this type of study; however, we sought a priori advice from our local Research and Development department regarding the conduct of this study.
A questionnaire based on the RCoA curriculum and the DAS 2015 guidelines was designed using Microsoft Word®.,, The questionnaire was piloted with anesthetic trainees in the local school of anesthesia and amended as necessary based on its results and feedback received from respondents. The questionnaire asked respondents' their professional demographics, time spent in airway modules, competence and self-rated confidence level in advanced airway techniques (on a scale of 1–10, 1 being not at all confident and 10 being highly confident), approximate number times a procedure had been performed to date, availability of training facilities including airway skills room, access to airway equipment, and barriers to training [Appendix 1 [Additional file 1]].
A list of all of the anesthetic college tutors in the UK was obtained from the RCoA website (https://www.rcoa.ac.uk/schools-of-anaesthesia- accessed on 15 July 2017) and the postal address for each hospital obtained from a Google search. This identified 331 college tutors at 265 individual hospitals/NHS Trusts. Where hospitals had more than one college tutor, the tutor appearing first alphabetically was selected to avoid duplication. A college tutor at every hospital in the UK was sent a pack containing a covering letter, a paper questionnaire enclosed in a sealed envelope, and a prepaid return envelope. The covering letter instructed college tutors to give the questionnaire to the most senior anesthetic trainee within their department provided they were of specialist trainee year 5 or above. The trainee placed the completed questionnaire in a sealed envelope for return to the researchers and remained anonymous. Their responses were not accessible by seniors within their department. Each paper survey contained a unique ID. A second and third round of paper surveys were posted to nonresponding college tutors at six-week intervals. At 12 weeks, nonresponding hospitals were reminded by email or telephone call. The survey began in September 2017 and closed in December 2017. Duplicate replies were removed with the most recent reply discarded. The responses were compiled and analyzed using Microsoft Excel®, GraphPad Prism 5® (GraphPad Software, La Jolla California, USA), and SPSS (Version 24, IBM Corporation, Armonk, New York, USA). Differences in median confidence score and number of procedures performed between higher and advanced level trainees were compared using two-tailed Mann–Whitney Utests and statistical significance was taken as P < 0.05.
| Results|| |
Questionnaires were sent to 265 college tutors. 28 departments stated that they did not have specialist trainees in year 5–7. Therefore, the total number of hospitals with senior anesthetics trainees was 237. A total of 166 completed replies were received; however, 17 were removed as they were duplicate forms from the same hospital and so 149 responses were included in the final analysis. The response rate was therefore 63%. The response rate was equal across the nations of the UK and hospital sizes. There were 100 responses from ST5-6 trainees and 49 from ST7 trainees.
The time spent in a dedicated airway rotation varied from less than a month to 1 year [Figure 1]. Five (3%) respondents did not report the amount of time they had spent in a dedicated airway rotation. The number of dedicated airway block rotations completed by respondents was variable. Nine (6%) respondents stated they had done no rotations in a formal airway block. Twenty-nine (19%), 38 (25%), 15 (10%), and two (1%) respondents had completed one, two, three, and four rotations in formal airway blocks respectively. Fifty-six (36%) respondents did not state how many airway blocks that had completed.
|Figure 1: Time senior anesthetic trainees had spent in a dedicated airway training block|
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Self-rated competence, confidence, and number of times advanced airway techniques were performed are summarized in [Table 1]. These varied greatly by technique, for example there was low confidence in the use of ultrasound for airway assessment and high confidence with videolaryngoscopy.
|Table 1: Competence and confidence of senior anesthetic trainees in advanced airway techniques and the number of procedures performed to date|
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The median (Interquartile range (IQR) [range]) confidence score in anesthetic list management for airway related surgery was 7 (5–8 [1–10]) and the number of lists managed ranged from 0 to 30. The median (IQR [range]) confidence score in front of neck access (surgical cricothyroidotomy) was 5 (3–6 [1–10]) and 29 (19%) respondents stated they have had an opportunity to assist with a formal surgical tracheostomy in theater.
A minority of respondents (58 [39%]) stated they received regular high-fidelity simulation training in airway emergencies and 26 (17%) of the respondents had training in airway emergencies with full theater team participation. Only 26 (17%) had access to an airway skills room in their current departments. The airway training workshops attended by respondents over the past two years is summarized in [Table 2] with manikin-based workshops being the most commonly attend (127 [60%]). The availability of airway equipment for clinical and training purposes was variable as represented in [Table 3].
|Table 2: Types of airway training workshops attended by senior anesthetic trainees in the past 2 years. Values are number (proportion of respondents)|
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|Table 3: Availability of airway equipment to senior anesthetic trainees in their current departments. Values are number (proportion)|
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With regard to videolaryngoscopy, 62 (36%) respondents had the most experience with the CMAC®, 49 (29%) with the Glidescope®, 40 (23%) with the McGrath, 16 (9%) with the Airtraq®, 2 (1%) with the Venner APA®, and 2 (1%) did not answer the question. Lack of learning opportunities and lack of training lists were the most commonly reported barriers to training [Table 4].
|Table 4: Barriers to airway training identified by senior anesthetic trainees|
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There were 53 (36%) respondents who had completed solely higher level airway training. This included 31 (58%) ST5-6 and 22 (42%) ST7 level trainees. Their competence in airway skills is summarized in [Table 5].
|Table 5: Competence in advanced airway techniques of senior anesthetic trainees who had completed higher level airway training only|
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In relation to advanced level airway training, 39 (26%) had completed or were currently undertaking training, 38 (26%) were planning to complete, and 71 (48%) had no plans to complete. One respondent did not answer the question. The confidence and number of times trainees had performed advanced airway procedures is compared between higher and advanced level trainees in [Table 6]. For all skills, advanced level trainees had performed more airway procedures and demonstrated greater confidence compared to trainees who had completed only higher level of training. This difference was statistically significant for several skills, including channeled videolaryngoscopy and FOI in awake patients and via a SAD. Significantly greater confidence was also demonstrated by advanced level trainees compared with higher level trainees for advanced extubation using the remifentanil technique (P = 0.0100) and the airway exchange catheter technique (P = 0.0244). Advanced level trainees had significantly greater confidence than higher level trainees in surgical cricothyroidotomy (P = 0.0256) and airway list management (P = 0.0060). Advanced level trainees had undertaken anesthetic list management of complex airway patients (P = 0.0322) and airway ultrasound assessment (P = 0.0491)significantly more frequently that higher level trainees.
|Table 6: Comparison between senior anesthetic trainees who had completed higher or advanced level airway training in airway technique confidence and number of procedures performed to date|
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| Discussion|| |
This national survey has evaluated advanced airway skills and airway training amongst senior anesthetic trainees in the UK. We have also evaluated their training opportunities, barriers to training, and provision of advanced airway equipment. A previous national survey addressed airway training from a trainer's perspective, however our survey has evaluated advanced airway skills and training directly at a trainee level. To our knowledge this represents the first national survey of its kind in which anesthetic trainees in UK have rated their competence, experience, and confidence across a wide range of advanced airway techniques, and in addition appraised the provision of training facilities, airway equipment, and barriers to training.
We have demonstrated a marked variability in exposure to formal airway training and completion of advanced level training modules. Similarly, trainee competence and experience were variable across the advanced airway skills investigated. Competence with videolaryngoscopes was high, as was confidence and experience. Encouragingly, more than half of trainees felt competent enough to teach others. A high confidence level was also seen with FOI in anesthetized patients and more than half were able to perform this skill independently. However, FOI in awake patients and FOI via a SAD were performed infrequently and with poor competence. This is a worrying finding given that awake FOI is the preferred technique in the majority of anticipated difficult intubations and NAP4 has identified many cases where awake FOI may have prevented harm occurring to patients. Despite this, FOI is performed uncommonly, and the application of videolaryngoscopy appears to have influenced this., This is likely to have impacted upon trainee exposure and therefore contributed to the poor trainee competence found in our survey. Poor competence and experience with advanced extubation techniques was also seen; notably the laryngeal mask airway (LMA) exchange and airway exchange catheter techniques. Furthermore, few trainees could independently use high frequency jet ventilation, perform percutaneous tracheostomy, or use ultrasound for airway assessment. All of these skills are recommended in the DAS 2015 guidelines. These worrying results are again likely due to the limited clinical opportunities available to practice and acquire this skill.
The limited exposure and competence with these infrequently performed techniques highlights the need for training outside of the clinical environment utilizing models and simulation. However, our survey has shown that the availability of simulation training, airway skills rooms, and airway equipment for training was sparse with many trainees having no access at all. The availability of airway training facilities was not universal and appears inadequate for many trainees nationally. This is concerning given our survey findings of poor competence and clinical experience with many advanced airway skills. It is known that regular training in any sphere of work is considered key to maintaining competency in skills performed infrequently. Locally accessible airway skills rooms allow for regular practice of these skills and enable focused and tailored training to meet the needs of individual trainees. In the UK, it is recommended that every department of anesthesia have an airway lead with a designated role for overseeing local airway training, designing local policies, and ensuring standardization of airway equipment. They could also play a role in setting up a local airway skills room. Although these carry immediate cost implications, they are likely to represent a long-term cost-effective training modality. With restricted study leave time and budgets, attending distant national courses may further compromise time spent in the clinical environment; highlighting the importance of a local airway skills facility. In addition to restricted availability of equipment, our survey identified additional barriers to airway training. The two most commonly reported barriers were lack of learning opportunities and lack of appropriate training lists. From a trainee's perspective, possible explanations for reduced learning opportunities in the clinical environment could be professional commitments outside of the clinical environment (e.g., class room teaching, mandatory training), the effect of the European Working Time Directive, and service provision commitments.,, From a trainer's perspective, lack of time for teaching has been reported in a previous study and further supported by the 2017 GMC national survey.,,
Regular multidisciplinary training in managing emergency situations, such as failed intubation and CICO scenarios, is necessary to develop and maintain expertise., Recent recommendations encourage multidisciplinary collaboration and airway training., Despite this, we found just 26 (17%) participants had training sessions with multidisciplinary theater team involvement. Targeted training for all specialties involved in managing airway emergencies is known to improve team dynamics and familiarity with the emergency airway management algorithms.
We have reassuringly demonstrated that advanced level trainees have greater confidence in advanced airway procedures and have performed them more frequently than higher level trainees. This difference was statistically significant for a number of the skills investigated. Our survey supports the notion that advanced level airway training allows trainees to gain greater exposure to complex airway skills and develop expertise.
In clinical practice, opportunities for training in complex airway skills and exposure to difficult airways is sporadic and are often emergent in nature. A trainee's placement may not match their learning requirements, therefore limiting training opportunities. The probability of encountering a difficult airway can be low. The overall FOI rate in a UK teaching institution has been reported as just 1.2% of total tracheal intubations and the rate of awake FOI as 1.71% of all general anesthetics. There is a significant negative correlation between the rate of complications associated with awake FOI and experience of the operator. Therefore, well-structured training supplemented by teaching modalities outside the operating theater such as endoscopy simulators, nasendoscopy in the ENT clinic, and endoscopy in bronchoscopy clinics is essential. Teaching time is always precious as the trainer and trainee have to strike a balance between training time and service provision demands. Heavy workloads remain a concern with more than 40% of trainers reporting their working day as heavy. Once a competency is achieved, regular practice is essential to prevent skill deterioration. Deliberate practice, evaluation of performance, modification of behavior, and regular opportunities to practice are key elements in gaining expertise in advanced airway skills such as awake FOI and at risk extubation techniques. The learning curve for technical skills is biphasic in nature, with roughly 80% competency achieved over approximately 30 cases, but for continued improvement in performance over 100 cases may be required. Adequate clinical exposure is therefore imperative.
The main limitation to our study is the selection bias inherent to this type of survey methodology. Whilst we have obtained a reasonable response rate for this national survey, the nonresponders form a sample not represented in our data. Furthermore, the methodology of the college tutor passing on the survey to a senior anesthetic trainee may have generated a selection bias. This however, was the best practical solution to eliminate duplicate responses and gain an authentic representation required of a national survey. We recognize that the survey results depend on the accuracy of information provided by the respondents. We asked respondents to state the approximate number of procedures performed during their training career. An acceptability bias is possible within these responses; possibly amplified in those completing advanced level training. The risk of this was reduced by ensuring the survey was anonymized. Detailed definitions of the techniques were not provided and hence individual trainee's understanding of some procedures may have influenced their responses. We also recognize that there is a possibility of interindividual variability in rating their confidence.
| Conclusion|| |
Our survey highlights the deficiencies in advanced airway skills amongst senior anesthetic trainees in the UK. Confidence, competence, and practical experience were satisfactory for some skills such as videolaryngoscopy and asleep FOI. However, sufficient experience with awake FOI, FOI via a SAD, high frequency jet ventilation, and at risk extubation techniques was lacking amongst a majority of senior anesthetic trainees; particularly those who had not completed advanced level airway training. Lack of multidisciplinary training, coexistent deficiency of dedicated airway skills rooms, lack of learning opportunities, and lack of teaching time were identified as the key barriers to training.
With limited availability of training resources, it is a challenge to ensure that trainees have uniform and adequate competencies in all advanced airway skills. Therefore, it may be necessary to restructure the existing airway training program to produce future airway specialists. There is a precedent for this after the revealing NAP4 report and resulting widely accepted recommendations.,,, Perhaps this could be achieved with enhanced and targeted training at the advanced airway level, along with improved provision of airway skills rooms and equipment for training purposes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: Results of the fourth national audit project of the Royal college of anaesthetists and the difficult airway society. Part 1: Anaesthesia. Br J Anaesth 2011;106:617-31.
Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway management in the emergency department: A one-year study of 610 tracheal intubations. Ann Emerg Med 1998;31:325-32.
Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: Results of the fourth national audit project of the Royal college of anaesthetists and the difficult airway society. Part 2: Intensive care and emergency departments. Br J Anaesth 2011;106:632-42.
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al
. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.
The Royal College of Anaesthetists. Curriculum for a CCT in Anaesthetics Version 1.8. 2010.
Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult airway society guidelines for the management of tracheal extubation. Anaesthesia 2012;67:318-40.
Baker P. Preparedness and education in airway management. Anesthesiol Clin 2015;33:381-95.
Goldmann K, Ferson DZ. Education and training in airway management. Best Pract Res Clin Anaesthesiol 2005;19:717-32.
Wanderer JP, Ehrenfeld JM, Sandberg WS, Epstein RH. The changing scope of difficult airway management. Can J Anaesth 2013;60:1022-4.
El-Boghdadly K, Onwochei DN, Cuddihy J, Ahmad I. A prospective cohort study of awake fibreoptic intubation practice at a tertiary centre. Anaesthesia 2017;72:694-703.
Wiles MD, McCahon RA, Armstrong JAM. An audit of fibreoptic intubation training opportunities in a UK teaching hospital. J Anesthesiol 2014;2014:4.
Stringer KR, Bajenov S, Yentis SM. Training in airway management. Anaesthesia 2002;57:967-83.
Sim DJ, Wrigley SR, Harris S. Effects of the European working time directive on anaesthetic training in the United Kingdom. Anaesthesia 2004;59:781-4.
England AJ, Jenkins BJ. Time spent in the clinical environment is the most important aspect of medical education-We need to protect it. Anaesthesia 2017;72:1306-11.
Kristensen MS, Teoh WH, Rudolph SS. Ultrasonographic identification of the cricothyroid membrane: Best evidence, techniques, and clinical impact. Br J Anaesth 2016;117(Suppl 1):i39-48.
Patel A, Nouraei SA. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE): A physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia 2015;70:323-9.
Lindkaer Jensen NH, Cook TM, Kelly FE. A national survey of practical airway training in UK anaesthetic departments. Time for a national policy? Anaesthesia 2016;71:1273-9.
Marshall SD, Chrimes N. Time for a breath of fresh air: Rethinking training in airway management. Anaesthesia 2016;71:1259-64.
Pracy JP, Brennan L, Cook TM, Hartle AJ, Marks RJ, McGrath BA, et al
. Surgical intervention during a can't intubate can't oxygenate (CICO) event: Emergency front-of-neck airway (FONA)? Br J Anaesth 2016;117:426-8.
Ahmad I, Bailey CR. Time to abandon awake fibreoptic intubation? Anaesthesia 2016;71:12-6.
Fitzgerald E, Hodzovic I, Smith AF. 'From darkness into light': Time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia 2015;70:387-92.
Hammond F, Saba M, Simes T, Cross R. Advanced life support: Retention of registered nurses' knowledge 18 months after initial training. Aust Crit Care 2000;13:99-104.
Cook T, Woodall N, Frerk C, O'Sullivan E, McNarry A, Drake S, Grocott M. The RCOA-DAS Departmental airway lead and NAP4 follow-up surveys: An announcement. Bull Royal Coll Anaesth 2012;76:37-8.
McIndoe AK. Modern anaesthesia training: Is it good enough? Br J Anaesth 2012;109:16-20.
General Medical Council. Training environments 2017: Key findings from the national training surveys; 2017.
Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med 2004;79 (10 Suppl):S70-81.
Greaves JD. Training time and consultant practice. Br J Anaesth 2005;95:581-3.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]