To meet the challenges of evolving health care and medical education, the residency training curriculum undergoes changes at regular intervals by local and national graduate medical education oversight bodies. The recent pandemic significantly impacted learning opportunities for residents across all specialties. Teaching medical skills is an art and science simultaneously. The residency training curriculum serves as the most important framework to provide trainees with sufficient medical knowledge, skills, and judgment necessary to be independent practitioners. Notably, we face a critical dilemma between our duty to educate and provide the safest care for patients, all the while respecting our patients’ autonomy, beneficence, non-maleficence, and consent to undergo procedures by trainees (Anaesthesia 2018;73:940-5).
In anesthesiology, procedural skills play an essential role in helping to deliver safe patient care, and airway management is the most complex of those. In general, teaching airway management includes three components – anatomical knowledge, procedural proficiency, and clinical judgment. This includes a broad variety of skills: airway maneuvers to maintain airway patency during sedation cases, bag mask ventilation, supraglottic device placement, direct and video laryngoscopies, flexible scope intubation, combined use of available devices (i.e., hybrid techniques), and surgical airway. A comprehensive curriculum emphasizing learning, practice, and mastery in all the above domains is vital. Anesthesiologists are the experts in airway management, and anesthesia residents are expected to graduate from residency with the ability to manage a difficult airway in the OR as well as in any other location.
It is prudent to divide airway management teaching into two categories: teaching basic airway management to new trainees and teaching advanced skills of complex airway management to more advanced learners (A A Pract 2019;13:197-9). Historically, airway management was taught in the OR on patients undergoing anesthesia until manikins were developed. The first life-size doll known as “Resusci Anne” was developed by a toy company and an anesthesiologist in the early 1960s. Gradually, manikins became part of simulation training for learners before patient encounters. With the development of airway simulators/manikins, it became common to introduce trainees to basic and advanced airway management skills using medical simulation technology. Manikins lack the salient features of the human airway, e.g., tissue feel, dynamic nature of the structures, mucosal membrane secretions, tissue hue and luster, mobility of the cervical skeleton with manipulation, to name a few. Still, manikins became an essential part of teaching airway management skills from direct laryngoscopy to flexible scope intubation. It is ethically challenging to design randomized studies to compare teaching airway management using actual patients versus airway manikins (Anaesthesia 2016;71:1399-1403). While simulated airways might not reproduce actual airway anatomy perfectly, with impressive advances in manikin technology, they provide an opportunity to learn basic and advanced techniques in a controlled and safe environment.
In a meta-analysis, Kennedy et al. included studies reporting advanced airway skill instruction using simulation. They included 76 studies with 5,226 enrolled trainees. This meta-analysis showed a statistically significant favorable effect on airway skills in the simulation group when compared with no simulation training. The comparison between simulation training versus non-simulation instruction revealed that simulation training was superior for patient outcomes, trainee satisfaction, practice behavior, and non-timed skills, while timed skills and knowledge were comparable in both forms of training groups. Interestingly, within the simulations, those using an animal model or cadaver instead of manikins showed higher trainee satisfaction (Crit Care Med 2014;42:169-78).
These two reviews make it obvious that curricula based on simulation indicate better trainee satisfaction and skill level. In addition, simulation using biological models (animal and cadaver) may be a better tool when compared with manikins or OR-based simulation.
The wide variety of airway devices available in the market makes the training of residents biased toward the devices traditionally used at one’s training institution. Familiarizing residents with the full spectrum of devices can provide them with broader insight when entering independent practice. Currently, devices like Bullard and Shikani scopes and lightwand stylets are being replaced by newly developed video laryngoscopes. Video-assisted laryngoscopy is mainly represented by Glidescope, McGrath, and AirTraq (Expert Rev Med Devices 2018;15:631-43).
A panel of experts in anesthesia education and airway management convened to address the deficiencies in defined airway curricula in 2019. According to their recommendation, the teaching of airway skills should have four aspects: a self-guided web-based module, hands-on skill training via simulation, a checklist assessment of competency with manikin/simulation, and a direct observation scale for assessment during clinical care. The panel recommended a two-fold program, namely an airway management boot camp curriculum and an advanced airway management curriculum. After a vigorous and thorough peer-review process, an online resource called “Anesthesia Toolbox” was created; materials included lecture slides, problem-based learning discussions, e-learning modules, podcasts, standardized cases, hands-on skill training guides, simulation scripts, quizzes, and reading lists of landmark/key articles (Anaesthesia 2018;73:940-5).
Anesthesiology residents often start their training with basic exercises in airway management either during medical school rotations or internship training. Many anesthesiology departments have well-organized curricula, including a “boot camp” introduction course at the beginning of residency with manikin airway simulators and an opportunity to practice basic skills. These focused sessions help make the transition from manikin to human safer for patients and less stressful for trainees. Studies in critical care fellows show that skills obtained through simulation-based training effectively prepare them for urgent critical care airway management. The pulmonary critical care medicine fellows who participated in the simulation-based training during their first month of the fellowship were evaluated using a video-based scoring checklist. They performed critical care airway management in three different situations: in a simulation environment, during real-life patient encounters, and during their second and third year of training. The assessment scores showed that airway management skills acquired during simulation training were effectively transferred into real-life practice and maintained during their fellowship training (Chest 2020;158:272-8).
For more advanced airway management skills, residency programs may have a difficult airway rotation with case assignments involving either ENT, bariatric patients, or known complicated airway cases; according to a survey in 2011, almost half of the residency programs had an airway rotation (J Clin Anesth 2011;23:15-26). During the airway rotation, residents have opportunities to practice airway assessment, difficult airway management planning, and selection of the appropriate equipment and techniques under close supervision. This supervised experience not only teaches them technical skills but improves their judgment and ability to collaborate with a team to achieve complex tasks. The specific subspecialty airway management considerations are taught during trauma anesthesia, pediatric anesthesia, and obstetric anesthesia, but they are not universally organized as separate airway curriculums. Airway assessment and management were part of the study on general anesthesia for emergency C-sections but were not specifically designed to address potential difficult airways in obstetric patients (Braz J Anesthesiol 2021;71:254-8).
Airway management is not limited to procedural skills and competency. Clinical decision-making and judgment are skills learned during residency training. In case of an unanticipated difficult airway in the OR, the situation may make it necessary that the most experienced provider takes over since multiple intubating attempts are associated with an increased risk of adverse events; and trainees may learn best by directly observing the decision-making process (Emerg Med J 2019;36:520-8). “Preconditioning” for the difficult airway management decision is well addressed in problem-based learning discussions and simulation sessions that include crisis and resource management and complex airway management algorithms. Often, simulation sessions include procedural parts, and that combination probably provides trainees with the best opportunities to manage these cases independently. Moreover, video recording and debriefing can further open opportunities for self-reflection and improvement.
One skill anesthesiologists traditionally feel least comfortable with is the surgical airway, which includes cricothyrotomy, tracheostomy, and retrograde intubation. Fortunately, due to advances in airway management equipment and techniques, these are rarely used. Techniques utilized for educational purposes include practice on a manikin, cadaver workshop, and large laboratory animal specimen workshops (e.g., pig larynx-trachea). According to a 2010 survey of residency programs, 65% of programs taught surgical airway management using a single method, and 35% used several modalities. The most commonly used modality was practice on the manikin (57%), and the other teaching methods included didactic teaching (31%), a cadaver workshop or large animal laboratory (29%), simulator training (24%), and reading material alone that were subject-specific (3%) (J Clin Anesth 2011;23:275-9).
In the last two decades, the revolution in personal electronic devices (PED) has opened new learning avenues. There are a handful of smartphone-based applications for airway simulation, and each one of them has advantages and disadvantages. These applications are very useful for even novices to learn airway anatomy and provide a realistic opportunity for learners to practice skills by simulation at the time and place of their choice. The residency programs often encourage trainees to use these applications to increase familiarity, enhance skills, and learn variations in airway anatomy.
Airway management is a lifelong learning skill. Currently, it is hard to imagine any CME conference or specialty/subspecialty meeting that would not offer an advanced course on airway management. A difficult airway management curriculum might become standard across all residency programs. The future of airway education probably lies in simulation, based on the applications for PED, web-based learning modules, manikin, and biologic models, and ultimately patient airway management under supervision. Also, insights in team building and working in a team to perform complex tasks are necessary domains for exposing anesthesia residents to the necessary training so they can meet the challenges of the future. Exposure and training in team collaboration and communication in complex situations may be helpful to trainees for future airway challenges.