Discussion

 

 

For successful airway management (AM), structured airway training programs for anestheia residents are needed. Based on the results of a comprehensive survey questionnaire, we also evaluated to which extend these needs are fulfilled at anesthesia departments in Austria.

 

Study Limitations

 

The study has some limitations. The questionnaire forms were mailed to the clinical directors; their answers may not necessarily be in accordance with those of the staff anesthetists of the departments. The major limitation of this survey questionnaire may be the relatively low response rate of 66 percent restricting the accuracy of the responses. Furthermore, we do not know the real number of the departments educating anesthesia residents. 

 

Education of Anesthesia Residents

 

In this survey for the year 2004, the participating departments educated 328 anesthesia residents; 70 percent of the departments had full authorization for education. In Austria, authorization for anesthesia residency training and the number of assigned trainees depend on the work load and the operative departments established at the institution; there are no standards to which training should conform and there are no visitation programs for quality control of teaching and training of anesthesia residents.    

 

Training Facilities

 

Traditional training methods may not ensure that current anesthesia residents acquire the necessary knowledge and skills in routine AM techniques, including face-mask ventilation (MV), use of laryngeal mask airways (LMAs), and conventional laryngoscopy (CL) and tracheal intubation, and in advanced AM techniques, including at least flexible bronchoscopy-assisted (FBA) tracheal intubation (8). One of the most important reason is that anesthesia residents spend less time in operating areas and therefore are exposed to fewer cases in general; much time is instead spend on other aspects of training, such as preoperative patient evaluation, pain management, and perioperative and intensive care medicine. In addition, in Europe the hours of duty for residents have been reduced by the European working time directive. Another reason that traditional training methods may be lacking relates to changes in anesthetic practice: increased use of regional anesthesia techniques and LMAs has greatly reduced the exposure to MV and tracheal intubation. Therefore, it is imperative that anesthesia residency training in AM techniques has to become more structured.

 

Training of Advanced Airway Management Techniques

 

Ovassapian initiated an educational program for FBA tracheal intubation [published in 1988 (14)]; he advocated that no operator should perform an unfamiliar task for AM on patients without studying and developing the required base of knowledge in its performance (15). This program provided formal hands-on training on airway models for acquisition of sufficient skills before performance on patients under instruction by an experienced user of these techniques. 

 

Cooper and Benumof (3) developed an airway rotation program for anesthesia residents in which more than one AM technique is practised on each patient; we consider this method of repeated airway manipulations with different devices on the same patient unethical because of exposing the patient to unnecessary instrumentations. The program for airway rotation described by Dunn and co-workers (5) implemented at their department is exemplary. This program consists of two one-month rotations during anesthesia residency training, first in basic and later in advanced AM techniques; there is a list of restricted, but evaluated AM techniques that an anesthesia resident must perform under guidance of experienced instructors to successfully complete the rotations.

 

Dedicated airway rotation programs maximize exposure to devices and techniques for AM, but only 8 percent of the departments had incorporated airway rotations for advanced AM techniques with duration of at least one month in their residency training. A similar situation was found in a recently published survey performed in Germany including only university and university-affiliated teaching hospitals (7); also teaching institutions in the United States do not regularly provide airway rotation programs (9). Airway rotations should only serve as an introduction for anesthesia residents; practice of advanced AM techniques must be provided throughout the remainder of their residency training, particularly during surgical subspeciality rotations, for example during rotation through maxillofacial and pediatric surgery, with increasing training opportunities also in difficult and sensitive situations.   

 

Traditional training methods for advanced AM techniques using training opportunities on variably assigned patients were provided in 72 percent. Regular training was offered in 32 percent and may be a valuable alternative to structured training programs with airway rotations, but probably requires more experienced instructors. Occasional training was offered in 40 percent; we consider this training modality as insufficient to prepare anesthesia residents for independent management of difficult airway (DA) situations.

 

In 20 percent, educated AM techniques were restricted to MV, use of LMAs, and CL and tracheal intubation. Managing DAs without skills in advanced AM techniques represents substandard care and requires no further comments. 

 

Teaching and training of AM techniques on airway models have been instituted since many years, particularly for emergency medicine residents and paramedics. Anesthesia residents should also first acquire experiences with AM techniques on models before practising them on patients (18). With prior training on airway models, anesthesia residents are already familiar with with the devices and techniques when attempting them on patients and may shorten the learning curves, but training on airway models was provided in only 48 percent. In a recently published survey performed in Canada (11), only 30 percent of the responders had opportunities of training on airway models during their anesthesia residency training.    

 

Anesthesia residency training programs have been traditionally focused mainly on acquiring technical skills, but mastering a DA situation requires much more than just performing the steps of a technical procedure (12). Simulation systems are best for practising and testing competence and decision-making in DA scenarios, including failed ventilation and tracheal intubation situations, with emphasis on adherence to formulated DA management strategies (6, 17), but these training opportunities were offered in only 10 percent. Mandatory courses for anesthesia residents with simulator training of DA scenarios as prerequite to certify as specialist anesthetist are already implemented in Denmark (16) and The Netherlands (2); all European countries should follow these directives.

 

Assessment of Performance

 

The findings that formulted case number requirements for successfully performed AM techiques were provided in only 20 percent is not surprising. In Austria, there are currently no implemented requirements for anesthesia residents to perform a certain number of specific AM techniques, except the performance of at least 10 FBA tracheal intubations,  necessary to certify as specialist anesthetist and the European Board of Anaesthesiology published only minimum standards of training and expertise without specifying AM techniques (6).

 

Regular checking of successfuly performed AM techniques is essential to trace the developing competence of anesthesia residents but this surveillance was provided in only 18 percent. Anesthesia residents should be demanded to use their logbook also for listing of (un)successfully performed airway interventions as recommended by the European Board of Anaesthesiology (6); both complete success or failure with the techniques applied, confirmed by the instructor or the supervising staff anesthetist, are relevant for accurate evaluation of technical performance and clinical competence. 

 

Availability of Experienced Instructors

 

In 70 percent, at least one experienced instructor for teaching and training of anesthesia residents in advanced AM techniques was available. This high percentage is probably overestimated because there is little guidance for staff anesthetists serving as teachers and trainers of anesthesia residents. Staff anesthetists in general are not trained as educators; they usually have no formal training in educational psychiology and methology and frequently they do not use all the educational resources available. These needs may be filled by special courses for instructors to become highly qualified educators.

 

Conclusions

 

We demonstrated that there is much room for improvements in residency training in AM techniques at anesthesia departments in Austria. Benchmarking with the results of this survey and refining departmental directives may contribute to improved residency training.  

 

 

References