Structured Teaching and Training of Anesthesia Residents
Structured teaching and training of airway management (AM) techniques and practising strategies for difficult airway (DA) management should be an integral part of any anesthesia residency training program (4, 8). 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 (5, 19). With prior training on airway models, anesthesia residents are already familiar with the devices and techniques when attempting them on patients and may shorten the learning curves.
Traditional training methods using training opportuities on variably assigned patients cannot ensure that current anesthesia residents acquire the necessary knowledge and skills for successful management of DAs (9). 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 laryngeal mask airways (LMAs) has greatly reduced exposure to face-mask ventilation (MV) and tracheal intubation. Therefore, it is imperative that anesthesia residency training in AM techniques has to become more structured.
The process in which anesthesia residents are educated in AM techniques is variable and frequently nonuniform, although there exist efficient methods of instruction with dedicated airway rotations to maximize exposure to evaluated devices and techniques for AM. Cooper and Benumof (3) developed an airway rotation program in which more than one AM technique is practised on each patient; we consider this method of repeated airway manipulation with different devices on the same patient unethical because of exposing the patient to unnecessary instrumentations. The program described by Dunn and co-workers (6) implemented at their institution is exemplary. This program consists of two one-month airway rotations during anesthesia residency, first in basic practices, including face-mask ventilation (MV), use of laryngeal mask airways (LMAs), and conventional laryngoscopy (CL) and tracheal intubation, and later in advanced techniques, including flexible-bronchoscopy assisted (FBA) tracheal intubation; 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.
Crosby and Lane (5) recently reported their experiences with the development and implementation of airway rotation programs for advanced AM techniques. They stressed that 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 increased training opportunities also in difficult and sensitive situations. AM techniques that are used regularly and are considered safe for patient care, such as FBA assisted tracheal intubation techniques, can be used for training purposs without obtaining specific patient consent.
Anesthesia residency training programs have traditionally focused mainly on acquiring technical skills, but mastering a DA situation requires much more than just performing the steps of a technical procedure (15). Simulation systems are best for testing and improving competence and decision-making in various DA scenarios, including failed ventilation and tracheal intubation situations, with emphasis on adherence to formulated DA management strategies (22). Regular attendance on special workshops for anesthesia residents including simulator training as a prerequisite to certify as specialist anesthetist is already implemented in Denmark (17) and The Netherlands (1); all European countries should follow these directives.
Invasive AM techniques, for instance percutaneous transtracheal catheter insertion and percutaneous cricothyrotomy, that are used only in extremely rare and desperate emergency situations, should be learned and practiced on suitable models.
Recommendations of the Autrian Working Group for Airway Management
We highly recommend the provision of structured AM teaching and training programs for anesthesia residents with a stepwise approach from basic practices, including MV, use of LMAs, and CL and tracheal intubation, to advanced techniques, including at least FBA tracheal intubation. The use of airway devices and techniques should be first learned on airway models before practice on patients. We recommend the implementation of two separate one-month airway rotations first in basic practices and later in advanced techniques; practice of advanced AM techniques should be provided throughout the remainder of residency training. We further emphasize that anesthesia residents should be trained also on simulation systems and should learn and practice invasive AM techniques on suitable airway models.
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