Training Program for Anesthesia Residents

 

 

Ovassapian [as described in the first edition of his textbook (9)] later replaced the initial exposure of laryngeal structures by nasopharyngeal laryngoscopy (in patients recovering from general general anesthesia at the postanesthesia care unit) by training of these skills on an airway model. In addition, awake oral replaced awake nasal as the route of choice for flexible bronchoscopy-assisted (FBA) tracheal intubation as the experiences increased with both techniques. FBA orotracheal and nasotracheal intubation were subsequently practised on patients under general anesthesia.

With time, he further refined the training program for anesthesia residents [as described in the second edition of his textbook (10)] by starting with FBA orotracheal intubation (and nasotracheal intubation, when indicated) under general anesthesia (at this time frequently practised at his institution) instead of first training of awake FBA tracheal intubation. This expanded the number of patients available (without the need of their informed consent) and the opportunities for anesthesia residents to train these techniques in clinical situations. He then routinely used video camera systems for teaching and demonstration purposes. The refined program and the objectives for teaching and training FBA tracheal intubation and airway evaluation to anesthesia residents are outlined below.

Lectures, Instruction, and Practice on Models (Tracheal Intubation)

The knowledge of the basic physical principles involved in the construction of flexible fiberoptic bronchoscopes (FFBs) is essential for understanding of their function and avoiding damage of these expensive and delicate endoscopes; unnecessary damage to the FFB is not only costly, but also means that the FFB is for some time unavailable for use in clinical practice. The novice operator should have a clear understanding of the benefits of FFBs in tracheal intubation and airway evaluation and also of their limitations. This knowledge can be imparted by lectures and additional educational material.

The handling and maneuvering of FFBs should be first trained on bronchoscopy teaching and airway models under instructor supervision, without restricting the time for gaining confidence. Training on models can be done at any time, and valuable operating room time will not be consumed for this purpose. Practice should cover FBA orotracheal and nasotracheal intubation, including maneuvers for advancing the tracheal tube (TT) through the laryngeal aperture, verification of proper midtracheal TT position, and exchange of TTs.

Practice on Patients (Tracheal Intubation)

The instructor should first demonstrate the techniques in general to the resident on selected patients. Ideal patients for the initial clinical applications (starting with FBA orotracheal intubation) are those which undergo routine surgical procedures with normal airway anatomy; even routine patients may represent challenges (problems with secretions, fogging of the optical system, identification of anatomical structures, and TT advancement) to the novice operator in clinical practice. The resident should gain confidence in handling these routine problems before managing difficult situations. Exposure of laryngeal structures in anesthetized and intubated patients may be additionally used for training the resident in FBA exchange of TTs. Assistance of others performing these techniques (essential for success) must also be trained.

Lectures, Instruction, and Practice on Models (Placement and Positioning of Double-Lumen Bronchial Tubes and Bronchial Blockers)

Because of the far less oportunities of training FBA placement and (re)positioning of double-lumen bronchial tubes and bronchial blockers on patients, the resident should be instucted on a bronchoscopy teaching model in detail. The specific bronchial anatomy, along with the causes of bronchial intubation failures and malpositions can be fully demonstrated and discussed. With extensive practice of all these techniques on the model, the resident will be well prepared to perform them with sufficient expertise on an actual patient.

Practice on Patients (Placement and Positioning of Double-Lumen Bronchial Tubes and Bronchial Blockers)

The FFB should be routinely used in the placement and positioning of all double-lumen bronchial tubes and bronchial blockers. The FFB remains then in the operating room for ready availability to evaluate, correct, and manage any tube displacement and/or problem with gas exchange after lateral positioning of the patient and during the surgical procedure.

Evaluation and Management of Compromized and Difficult Airways

When the residents gained confidence and proficiency with FBA tracheal intubation and airway evaluation in patients with normal airway anatomy, they should also perform these techniques in difficult situations, including failed conventional laryngoscopy and planned awake FBA tracheal intubation. They should also use the FFB for perioperative evaluation and management of the compromised airway under various conditions (for example, when there is evidence for upper or lower airway obstruction), and for TT exchange.
 

 

Introduction of Flexible Bronchoscopy-Assisted Techniques into Anesthetic Practice