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):
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.
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:
Focused needs assessment
Prerequisites for training
Clear and specific goals and objectives
Scenario development—teaching the skill
Although this list might look daunting, each element can be satisfied quickly and can result in an effective in-house training experience.
220.127.116.11 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.
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.
18.104.22.168 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.
22.214.171.124 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.
126.96.36.199 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
- 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.
188.8.131.52 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.
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.
184.108.40.206 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:
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.
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.
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.
Hybrid simulation is a combination of high-fidelity simulators with either task-orientated simulators or patient actors.
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™.
An adapted gas can being used for fiberoptic dexterity.
Dexter Endoscopic Simulator®.
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.
Table 61-1 Simulator Companies
Table 61-2 Examples of Available Simulation Devices ||Download (.pdf)
Table 61-2 Examples of Available Simulation Devices
|Device||Bag-Mask-Ventilation||Supraglottic Devices||Endotracheal Intubation||ENDOSCOPIC Intubation (Dexterity)||Surgical Airway||Price|
|Laerdal airway management trainer||X||X||X||$$$|
|Deluxe airway trainer||X||X||X||X||$$$|
|Cricoids stick simulator||X||$|
|Ambu airway management trainer||X||X||$$|
|Airway Larry adult airway management trainer||X||X||X||$$|
|Adult airway management trainer||X||X||X||$$$|
|Dexter Endoscopy Trainer||X||$$$|
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