Chapter 61. Teaching and Simulation for Airway Management

It is sometimes striking how difficult it is to teach airway management well, and to have the student learn it, even with a comprehensive immersion experience in airway management. This text serves as the syllabus for an airway management education program that places special emphasis on the identification and management of the difficult and failed airway. This program, which has trained over 3000 emergency airway practitioners, has undergone progressive improvement and innovation, and is now called The Difficult Airway Course: Emergency. It is one of a family of educational programs that now includes: The Difficult Airway Course: EMS and The Difficult Airway Course: Anesthesia.

Gas exchange is fundamental to airway management. Thus, an educational program intended to teach airway management must craft educational objectives that support this fundamental goal. These enabling objectives are crafted in language typified as: "By the end of this educational program the participant will…" The program of instruction must embrace the knowledge and skills that constitute the standard of care, and, in addition, teach best practices related to the provision of gas exchange for those patients who are unable to do so for themselves.

This chapter serves as a primer for an airway management education program that academic as well as private practice practitioners can apply to their practice to improve both their airway management skills as well as the skills of their health care team. This chapter places special emphasis on the application of simple, easily applied hands-on experiences to improve the identification and management of the difficult and failed airway.

The objectives of a comprehensive airway program should contain five easily identified components. These are:

1. The results of a local needs assessment identifying training issues as well as a focused curriculum.

2. A cognitive or didactic component: may be accomplished with either a self-guided reading program or a series of focused lectures.

3. A skills development component: a hands-on laboratory that teaches the nuances of the devices identified as the standard of care, and other relevant devices as supported by the local needs assessment, as well as best practice-based evidence or expert consensus.

4. A practical real-time experience: an opportunity to put it all together with hands-on cases that simulate a real-life situation.

5. An evaluation process of the program and a self-evaluation process for the participant.

This chapter will focus on providing guidance for the development and execution of an airway management/difficult airway educational program in one's own home institution. The following areas will be discussed:

• The problem.
• The evidence that simulation works, improving patient safety through education, training, and research.
• A serious look at the devices a practitioner might easily use to start a local simulation program.
• A curriculum focused on a needs assessment for your institution and the acquisition of requisite skills.
• A skeleton for a context-sensitive training program—ie, point-of-care or in situ simulation.

61.1.1 What Problems Are We Facing in Airway Management?

Airway management is the scaffolding upon which the whole practice of anesthesia is built, and is part and parcel of other providers practice, such as emergency physicians, critical care specialists, hospitalists, and prehospital practitioners.1 Important as excellence in airway management has become, equally critical is the context in which one finds oneself when managing an airway (see Chapter 6). The context is clearly different for each of these provider groups although in practice there is crossover, typically at the scene of an emergency airway. For this reason, airway management training programs for all disciplines must focus on the difficult and failed airway. Physicians, nurses, paramedics, emergency medical technicians (EMTs), and first responders often care for patients who are acutely ill or injured. In these situations, practitioners often find themselves in highly emotionally charged, urgent, high-stakes, high-risk environments.

Despite the multidisciplinary nature of airway management, the ultimate objective in training of all practitioners to be able to effectively manage airways and support gas exchange is the same. The practitioner must know what to do to manage the airway, when to do it, how to do it, when not to do certain things and how to get out of trouble when one finds oneself in difficulty. Each of these processes is potentially challenging. Proficient airway management requires one to master a host of anatomical, physiological, pharmacological, and technical aspects. The practitioner must know and understand the normal and pathological anatomy of the airway. These facts must then be integrated into an evaluation process that will lead to the selection of appropriate drugs and devices matching this particular setting. They must then be trained in the use of these drugs and devices. Critical to these decisions is developing the sense as to when might be the best time to intervene and then translate the intervention into real-life situations. A final complication is that frequently things do not go as planned and the practitioner must be able to rescue the situation (and the patient) if the initial plan fails.

Despite the development of new devices, strategies and algorithms to predict, manage, and secure the difficult airway, morbidity and mortality associated with failed gas exchange and airway problems, such as difficult intubation or unrecognized failed intubation remain high. As emphasis has been focused on improving airway management, it has become apparent how difficult it is to teach airway management well, and ensure that the trainee has mastered those skills critical to routine airway instrumentation, as well as those required for difficult and failed airway situations. The problem seems to lay both in the area of adequate skills acquisition as well as in the transfer of these skills and strategies to daily clinical practice. Common methods for airway management training have historically included lecture/cognitive instruction mixed with hands-on sessions with simple intubating mannequins and occasional animal models, or structured curricula in physician training programs.2 However, since the publication of To Err is Human, health care professionals have looked to high reliability industries, such as commercial aviation, for guidance on improving training as well as system safety.3 One of the most widely adopted aviation-derived approaches is simulation-based skills and team training.

61.2.1 Does Simulation Improve Performance?

Medical simulation has become increasingly popular over the last decade as a means for teaching a variety of skills to a broad spectrum of practitioners. However, has it been shown to be effective and does it change practice and improve outcomes? These are difficult measures to quantify given the lack of homogeneity of practitioner's clinical practice.

Do we need evidence that simulation is effective when the reality is that it's becoming less acceptable to perform procedures on patients when the practitioners have had little or no training with the required skills, have not been assessed for proficiency on the skill being employed, and have had no prior experience? The answer is obviously NO. The see one, do one, teach one method of training is not appropriate for high-risk but low-frequency events, such as cardiac or respiratory arrest and difficult or failed airway management.

Patients have become increasingly concerned that students, residents, and for that matter, fully trained practitioners, practice on them as they develop the required basic clinical skills or become skilled with new devices as they are introduced. With this change in attitude by patients, clinical medicine has become more focused on patient safety. This has helped to shift the many aspects of clinical skills training from the bedside to arenas where patients are not at risk and the learner is the focus of training. Educators have faced these challenges by restructuring curricula, developing small-group sessions, and increasing self-directed/independent learning opportunities. Nevertheless, a disconnect still exists between the classroom and the clinical environment. Medical simulation has been proposed as a tool to bridge this educational gap. In a meta-analysis recently conducted by Okuda et al, simulation-based training has been demonstrated to lead to improvements in skills.4 This improved performance was translated into improved medical knowledge, improved performance of basic skills, improved confidence in performance of procedures, improved teamwork and communication performance, improved clinical performance, and improved performance during retesting at a later date. Fewer studies have demonstrated direct improvements in clinical outcomes, but evidence to this effect is slowly accumulating.

Simulation training offers a controlled, safe, and reproducible environment which can be used to train and practice clinical interventions, especially for high-risk and low-frequency events. It has also been shown to be effective in acquiring clinical skills proficiency and improving performance and patient care in real clinical situations.5 But most importantly, it is through simulation that skills (cognitive as well as psychomotor) acquired in isolation can be translated into life-like clinical settings.

Anecdotally, simulation not only improves performance of skilled tasks but also reduces reaction time in stressful situations with practitioners feeling more confident in their abilities to respond to high-risk but low-frequency events.

Several studies have examined the effectiveness of airway management simulation training. There is a consensus that it improves performance.5-7 The efficacy appears to last for at least 6 to 8 weeks following initial training but needs to be repeated at intervals of 6 months or less for retention of technical and decision-making skills.6 Multiple sessions of moderate length, rather than single session of excessive length seem to provide better training experiences and retention of skills. Sessions of 75 to 90 minutes appear optimal.7

61.2.2 What Are the Potential Benefits of Simulation?

The potential benefits of simulation include:

• No risk to patients.
• Patients with a rare medical condition but every trainee needs to see.
• Practice on rare and uncommon but critical events—patients may never see but need to learn to manage.
• Participants can see the outcomes of their decisions and actions.
• Participants can be allowed to make errors—let them walk the plank.
• Identical scenarios can be presented to different clinicians or teams.
• Team training—crew resource management.
• Repetition and feedback to consolidate skills.

Simulation has emerged as a key educational resource in areas where a combination of cognitive and technical factors combines to force the participant to decide the best course of action. The evidence from the literature suggests that simulation enhances performance and that performance enhancement is sustained.8

There is also evidence that simulation enhances skills development for airway management skills, reducing the need for actual live patient training.5,9 This is fortunate in considering the costs of such training, the scarcity of real humans to practice on, and the need to find a surrogate training model, particularly as it is felt that a major cause of high intubation failure rates by airway practitioners is inadequate training and skills maintenance.

Our conclusions support the concept that in-house workshops employing simulation technologies need to be conducted to keep the health care teams that manage airways effective and proficient.

61.2.3 What Types of Simulation Environment Are Available?

Simulation can be a highly effective approach for the acquisition of knowledge, task and skills proficiency, decision making, and teamwork. It is especially effective in acquiring skills that require eye-hand coordination and ambidextrous maneuvers common to many airway management devices, such as bronchoscopy. This type of training also helps learners prepare to deal with unanticipated rare medical events, develops teamwork and communication skills, increases confidence, and improves performance. Once simulation has produced mastery of fundamental skills, it can expose trainees to difficult situations, abnormalities, and other problems. Advanced simulations can reinforce skills that have been previously learned. Consequently, simulation is not just for new trainees. It can be at least as useful for established practitioners who are constantly challenged to update their skills in response to rapid changes in clinical practice. Simulation offers the foundation for an interdisciplinary approach to education—equally appropriate for physicians, nurses, emergency medical technicians, therapists, technicians, phlebotomists, and other health professionals.

There are essentially three basic types of simulation environments:

61.2.3.1 Specialized Simulation Center

For those interested in developing their own simulation programs, simulation training can often occur in a specialized simulation center. A simulation center provides a quiet, focused, safe environment where trainees can practice skills, be assessed either individually or as teams, and continue to train until proficiency is attained. However, most practitioners do not have access to such a center.

61.2.3.2 In Situ Simulation Training

In recent years, a new arena for simulation training has emerged; point-of-care or what is most recently termed in situ training. In situ simulation has evolved as a particular form of simulation, distinct from simulation that is conducted in a simulation center. Patterson et al have published an excellent review on in situ simulation, including the challenges and results.10

In situ simulation does not replace simulation conducted in the simulation center. In fact, the objectives of training conducted in a simulation center are likely to be very different from the objectives of in situ simulation. Training based at a simulation center is often related to a curriculum or course and has objectives related to both technical and nontechnical proficiencies (eg, basic suturing skills, central line placement, direct laryngoscopy, endoscopic intubation, communication, and teamwork). On the other hand, in situ simulation allows teams to review and reinforce their skills and to solve problems in the clinical environment.

In situ simulation occurs in the actual clinical environment with participants who are on-duty clinical practitioners during their actual work day. As an educational tool, it promotes experiential learning by training the health care provider in the actual environment in which the practitioner is expected to use these skills. Experiences in simulation labs may accomplish this to some degree, but in situ simulation, by definition, is more closely aligned with the actual work of the health care practitioner and is more likely to achieve success for certain training objectives. It provides a method to improve teamwork, team communication, and safety in high-risk areas. Given that the simulation occurs in the clinical environment, there are opportunities to identify hazards and deficiencies in the clinical systems, the environment, and the practitioner team.

For those institutions that are just beginning to develop simulation programs, in situ simulation offers an opportunity to begin to expose clinical personnel to simulation at considerable cost savings over a bricks-and-mortar center.

61.2.3.3 Simulation via Training Programs

Simulation incorporated into specialized airway management training programs is offered in a variety of locations. Examples are those courses offered at national meetings such as the ASA and American College of Emergency Physicians (ACEP); and stand-alone courses such as Street Level Airway Management (SLAM), Airway Interventions and Management in Emergencies (AIME), and the Difficult Airway Courses (DAC).

61.3.1 How Do You Design an Educational Program to Teach Airway Management?

It is clear from the educational literature that no single method of education (classroom lecture alone, case studies alone, or skills labs alone) adequately teaches complex cognitive and technical skills, such as airway management. This is consistent with the experience of the authors over decades of education of health care practitioners at all levels. An instructional method that integrates didactic teaching, case studies, and skills development provides the most valuable educational experience. Simulation appears to be an educational technology that might just incorporate all of these methods into one coherent package.

Educational programs to teach airway management would ideally be sensitive to the context in which the practitioner practices, and present cases that they are likely to encounter. Context-sensitive airway management was discussed in Chapter 6. The context also drives the selection of devices and techniques that need to be taught.

The design of the curriculum has to be sensitive to the fact that that airway management in patients if performed badly may have dire consequences. Thus, it is a performance of critical skill. Reason has defined two basic mechanisms whereby practitioners deal with critical incidents11,12 (see Chapter 2):

1. A rule-based solution: In this strategy, on recognizing the event for what it is, one identifies and applies a solution that experience has shown will likely be useful in solving the problem. Recognizing the event involves a process called "similarity-matching"; based on recognizing that the characteristics of this event is similar to those of past events (ie, pattern recognition). The practitioner then selects the particular solution that is likely to be effective in solving the problem and resolving the threat. This presupposes that the practitioner has had sufficient experience with both the situation and the application of the rule to immediately recognize the problem and to know which rule to apply. This ability constitutes what is called "expertise." Unfortunately, difficult and failed airways are encountered infrequently in practice, and the individual experiences of the vast majority of practitioners are unlikely to have been sufficient to have them considered as experts in managing difficult and failed airways.

2. A knowledge-based solution: This is a ground-up, first-principles strategy whereby the practitioner, without substantial past experience with similar situations, attempts to find an appropriate solution. Not surprisingly, such strategies are time consuming, and if forced under pressure of time are more likely to result in failure.

Most airway practitioners, even on a daily basis, do not have sufficient clinical experience with difficult and failed airways to have in their minds a rule-based, organized approach to these airway dilemmas, or the time to build one from first principles (ie, a knowledge-based solution). For this reason a variety of tools such as mnemonics and preformulated airway algorithms have been crafted to aid rapid decision making such that the odds of making correct decisions are enhanced and the risk of making incorrect decisions are minimized (see Chapters 1 and 2). No other environment allows the practice of these tools better than simulation.

It is important, when designing an in-house simulation training experience to follow a formal, albeit simplified, curriculum process. A curriculum expresses in a concrete fashion how the knowledge acquired through the training process will be translated into practice. It also helps identify the actual training needs and gaps in the training process that might exist. Finally, a curriculum forms the instructional content, teaching strategies that one might use to train the selected skill, and helps identify the assessment and evaluation tools and outcome measures.

As one attempts to design an in-house training program for airway management, one must make some decisions:

• Does one need to focus the training on a single skill and a single practitioner (eg, endoscopic intubation)
• Is the focus more on a health care team (eg, difficult airway in a simulation center)
• Or is the focus on the health care team and the system in which that team works (eg, an airway rescue device in a specific health care setting—LMA Fastrach in an obstetric suite).

The curriculum development process in each of these scenarios is essentially the same, although the goals and objectives, the actual scenarios, and the assessment metrics may differ.

61.3.2 What Are the Necessary Components in Designing a Simulation Training Curriculum for Airway Management?

A typical, but simplified, training curriculum ought to embrace eight elements:

1. Focused needs assessment

2. Target trainees

3. Prerequisites for training

4. Clear and specific goals and objectives

5. Cognitive component

6. Scenario development—teaching the skill

7. Equipment

8. Outcome assessment

Although this list might look daunting, each element can be satisfied quickly and can result in an effective in-house training experience.

61.3.2.1 Focused Needs Assessment

As one begins to design an in-house airway management training program, it can be stated categorically that the single most critical step in the process is conducting a focused needs assessment. The authors cannot tell you which skills to select for training, but it is logical to select those devices that the practice group has found contextually useful.

Some airway management techniques and devices are so established that they constitute the standard of care and must be taught, such as bag-mask-ventilation (BMV), ventilation using extraglottic devices, laryngoscopy and orotracheal intubation, and cricothyrotomy. That is not to say that they must be taught as first-line interventions, but simply that they must be taught. As one progresses beyond the basic airway interventions, one is struck by the vast array of devices available to the practitioner. The marketplace has been flooded with airway management devices, and novel inventions seem to be introduced almost on a weekly basis. The reason is clear: airway management is difficult and dynamic. The ideal device that is easy to use and guarantees near 100% success has yet to be invented! So, those with expertise in the field must select those devices that are known to deliver an advantage over what currently exists and are supported by scientific evidence when available. Some of the advanced devices and techniques that have found their way into the management of the difficult and failed airway over the past several years include:

• The intubating stylets
• Extraglottic devices
• Rigid and semirigid optical stylets
• Video laryngoscopes
• Flexible endoscopic techniques (eg, bronchoscope)
• Percutaneous and open cricothyrotomy

By scanning this array of devices one begins to appreciate the need for specific training in the use of each. Complicating this task is the fact that at times, a recommended device or technique has particular relevance to a specific practitioner, a particular practice, or a unique practice environment (ie, is context sensitive). The best example is the prehospital environment where sterilization of reuseable devices is not ordinarily possible, rendering an advantage to single use, disposable devices (eg, Glidescope Cobalt® instead of the Glidescope Ranger®; disposable vs reuseable EGDs). Additionally, there are devices that ought not be taught to selected audiences because they may require high frequency of use to maintain competence, are too expensive, or confer little advantage to more simple existing devices or techniques.

61.3.2.2 Target Trainees

It is important to thoughtfully consider the training audience—are they novice or expert physicians, nurse anesthetists, medical/surgical nurses, respiratory therapists, paramedics, etc. This evaluation informs the analysis described in to the following paragraph.

61.3.2.3 Prerequisites for Training

To enable the trainees to focus on the skill central to the training, and to inform the content of the curriculum, it is important that an assessment of individual trainee cognitive knowledge and skill sets be performed prior to the training. This assessment will help target both the cognitive components and the technical components of the actual training session. The goal of the training session is dependent on this analysis to enhance its success.

61.3.2.4 Goals and Objectives

It is important to spend some time on constructing some clear goals and objectives targeted to the knowledge, skills, and attitudes that one wishes the trainee to achieve during the training. Given the unpredictable nature of in situ training, if that is to be incorporated into the session, the curriculum should focus on only one or at most two skill sets (eg, one or two airway rescue devices, one device and team communication, etc). The goals and objectives should be linked to critical action checklists that are sufficiently detailed to ensure the educational/assessment goals are met.

61.3.2.5 Cognitive Component

Nearly every training experience should have embedded within it a cognitive component that ensures the trainees are familiar with and understand such knowledge elements as:

• Required anatomy
• Physiology
• Pharmacology
• Specifics of the device(s)
• Team communication skills (if this is the focus of the training)

These elements can be delivered prior to the training session in lecture-type format, a web-based e-learning module, or in its simplest form a set of assigned readings. However, to be successful, the trainee must have in their possession basic knowledge of the skill/task that they are about to be expected to perform.

61.3.2.6 Scenario Development—Teaching the Skill

As one develops training around a task trainer, there is little need to craft a patient case or a formal training scenario. However, providing context to the trainee as they practice and become proficient with their skills adds to the learning environment. As an example, relating to the trainee instances when one has found the LMA-Fastrach™ beneficial while concomitantly relating the difficulties one found using the device in the clinical setting can add an additional dimension to their understanding of the use of the device.

As one begins to develop an in situ experience, the time spent on scenario development becomes more crucial. The patient history and physical examination, the clinical setting in which the trainee will "find the patient," and the physiological states (ie, vital signs, status of the airway, actions of the other team members) need to be addressed in much more detail. A well-crafted scenario will add realism to the case, elicit emotional responses from the trainee with which they must learn to contend, uncover cognitive decision-making skills or deficits, and finally test the workplace environment in which the trainee practices.

61.3.2.7 Equipment

There is a tendency during simulation experiences to use discarded hospital equipment or equipment that may not be currently employed by the practitioner(s). Training should be conducted using equipment that is in current use. As one moves from task training to in situ training, a detailed equipment list for conducting simulations will need to be generated. Nothing disrupts a simulation session more than not having the usual functional equipment, even the specific types of syringes etc, that the clinicians use. This highlights one of the major advantages of in situ training—the equipment the trainee uses in the simulation is usually the same as that available in day to day practice. Additionally, if an important piece of equipment is missing, the simulation has pointed out a systems error in the actual clinical environment. By correcting this fault, patient care and patient safety will be improved.

61.3.2.8 Outcome Assessment

One should attempt to develop explicit, overt, observable, measurable, and reproducible behaviors the trainee is expected to exhibit by the end of the training. There is a temptation to simply use trainee self-assessment questionnaires, that is, "do you feel you are now more capable of handling an airway emergency?" However, these do not identify the proficiency and skill level of the trainee.

61.3.3 How Do You Teach Fundamental Airway Skills?

The authors believe that health care practitioners find airway management stressful because some of the fundamental skills that are required in their daily practice are difficult to master and usually poorly taught.

Bag-mask-ventilation (BMV) is one of those skills. It is a skill that is at least as difficult to master as laryngoscopy and intubation. BMV requires a substantial amount of manual dexterity and practice to become proficient, and remain proficient. It remains enigmatic to the authors why BMV has not been relegated to a subsidiary position in basic airway management of the unresponsive patient in favor of easily taught and learned extraglottic devices such as the LMA or King LTS.

Laryngoscopy and orotracheal intubation is renowned as a difficult technique to master. This is backed up by the available literature that identifies roughly 50 orotracheal intubations being necessary to establish competence in the technique, defined as a 90% probability of success.13 It is a highly nuanced technique that requires detailed step-by-step teaching. The program of instruction must emphasize these nuances (eg, the critical importance of exerting pressure on the hyoepiglottic ligament when performing a curved blade intubation; employing an intubating stylet to facilitate intubation; how BURP is correctly performed; etc). Even the specific manipulations of the endotracheal tube during insertion may be critical to success.

The educational program must identify those details of technique (the tricks) that enhance success (ie, that little maneuver that makes the last 5% successful). At the same time, the program of instruction must reinforce true principles of management (eg, leave the dentures in for BMV, but remove them for tracheal intubation) and debunk well-established, but incorrect dogma (eg, smearing KY jelly on a beard makes mask seal during BMV easier).

Virtually all of the devices mentioned in the paragraph 3 of section 61.3.2 require detailed step-by-step instruction with respect to patient selection, preparation of the device, standard technique, and modifications to the technique in specific situations to achieve success, some more so than others. For example, optical stylets and video laryngoscopes are of limited value in the bloody airway and it is easier to teach and learn how to provide gas exchange to an unresponsive patient with a King LTS than to use BMV. Instruction on BMV is necessarily more intense than Combitube™ insertion because the former is a more difficult technique to master.

61.3.4 What Are the Advantages and Disadvantages in the Teaching Technologies?

Simulation can take the form of a number of device platforms including screen-based, task-oriented, high-fidelity mannequins, hybrid (to be discussed later), or cadaver/biologic specimen platforms. The location of the simulation may vary from formal bricks and mortar simulation centers to point-of-care or in situ simulation, each of which has its own limitations and benefits:

1. Screen-based simulators ordinarily present clinical scenarios designed to teach and reinforce cognitive decision making regarding airway management. However, they are not hands-on, do not teach dexterity or team communication, and so are not optimal for teaching airway skills.

2. Task-oriented simulators teach skills only. The spectrum ranges from home-made devices (eg, dexterity with a flexible endoscope using an adapted gas can (Figure 61-1.), or more sophisticated devices such as the Dexter Endoscopic Simulator® (Figure 61-2). However, no team communication or clinical scenarios can be practiced.

3. High-fidelity simulators are the computer-controlled, life-sized simulators with adaptable physiology. They are excellent for clinical scenario and team training in a realistic environment such as a virtual OR, but are less useful for individual skills acquisition.

4. Hybrid simulation is a combination of high-fidelity simulators with either task-orientated simulators or patient actors.

5. Cadaver/biologic specimens: Newly developed techniques of tissue preservation and embalming have enabled the production of cadaver tissues with life-like feel and resilience. These specimens are uniquely suited to airway management training. Biologic tissues can also be employed. Perhaps the best example is the use of pig tracheas to teach surgical airway management, as taught in the Difficult Airway Courses™.

There is a substantial variety of task-orientated and high-fidelity simulators currently in the market. Table 61-1 identifies the names and websites of several companies that make these devices, while Table 61-2 provides more detailed information about a selection of devices, what they can be used for, and an estimate of price. The list is not all inclusive and is devoid of any bias. The authors would recommend that individuals or institutions interested in purchasing any of the simulators contact a company representative to arrange for a demonstration and trial.

However, of all of these technologies, high-fidelity, simulation-based OR team training at the point of care has been identified as a method that best impacts effective teamwork performance in everyday practice.14

Gas exchange is fundamental to airway management. Educational programs that teach airway management and the use of airway devices must embrace this dictum by designing objectives to achieve this program goal. It is not about the device; it is about how to provide gas exchange to the patient!

Airway management has important and interrelated cognitive and psychomotor skill components. Educational programs that provide an element of didactic teaching, case studies that apply and reinforce the didactic content, skills teaching, and simulation integration in a real-life-simulated environment are best suited to the long-term acquisition of airway management skills.

With this in mind, the authors have attempted to demonstrate the efficacy, value, and relative ease with which airway management training incorporating simulation can be brought into both academic as well as large and small private practices and other training environments. The authors suggest that after identifying training need(s) for their specific practice groups (ie, context-sensitive airway devices), one should then set up a specific training experience using appropriate task trainers to acquire the skills and proficiency level desired. For those who have limited resources, that is, time and money, focused task-oriented skills training sessions employing low-fidelity devices coupled with in situ simulation experiences can add a new dimension to airway management training. Coupling these training platforms enhances the development of proficiency with airway devices and embeds this proficiency in daily clinical practice.

Embracing eight simple curriculum elements permits one to develop a training program that will change and enhance the clinical performance of individuals and teams. Finally, selecting the most appropriate simulation device(s) has the potential to reduce overall costs and maximize results.

Difficult and failed airway management training demands no less!!