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Anaesthesia, 2002, 57, pages 967–983
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REVIEW
Training in airway management
K. R. Stringer,1 S. Bajenov2* and S. M. Yentis3
1 Lecturer, 2 Locum Consultant ⁄ Instructor and 3 Consultant ⁄ Instructor, Magill Department of Anaesthesia, Intensive
Care & Pain Management ⁄ Chelsea & Westminster Hospital Medical Simulation and Training Centre, Chelsea &
Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK

Summary
Management of the airway is central to the practice of anaesthesia, yet trainees frequently feel
poorly trained in this area. A large range of skills needs to be acquired, but there are often problems
providing training on live patients. We review the different modalities available for training and
assessment in airway management.

Keywords Education: medical ⁄ methods. Anaesthesia: airway, ventilation, simulation. Intubation,

tracheal: fibreoptic. Equipment: laryngeal mask airway.
. ......................................................................................................
Correspondence to: Dr K. R. Stringer
*Present address: Consultant Anaesthetist, Department of Anaesthesia
and Pain Management, Royal North Shore Hospital, Pacific
Highway, St. Leonards, Sydney NSW 2065, Australia
Accepted: 9 July 2002

Management of the airway is central to the practice of with tracheal intubation and ventilation by facemask [4,
anaesthesia. Failure to maintain adequate gas exchange 5], the basics of airway management. Some have
can be catastrophic and may have important medicolegal suggested limiting the use of the laryngeal mask airway
implications. In the American Society of Anaesthesiolo- to help overcome this [6].
gists’ Closed Claims Analysis, adverse outcomes associated There has previously been little consensus on which
with respiratory events accounted for 37% of the cases airway skills should be taught to trainees and how best to
attributable solely to anaesthesia [1]. In 85% of these cases, teach them [4]. The Royal College of Anaesthetists
death or brain damage occurred and 72% were considered (RCA) provided a syllabus for the FRCA examinations in
preventable. The most common problems were inade- 1997 [7]. Aspects of airway management were covered
quate ventilation, oesophageal intubation and difficult within the various modules but there was no specific
tracheal intubation [2]. Care was considered to be airway syllabus. The same is true for the competency-
substandard in 90% of claims associated with inadequate based training document for senior house officers [8].
ventilation. However, the recently published corresponding docu-
Good skills in airway management include not only ment for specialist registrars years 1–2 [9] does contain an
technical proficiency with an increasingly complex and extensive airway syllabus, but with no requirement for a
wide range of equipment, but also the judgement and designated airway module. Very few hospitals have a
experience to use them appropriately. Traditionally, these structured airway block [10, 11]. The Association of
skills have been gained through ‘on-the-job’ experiential Anaesthetists of Great Britain and Ireland (AAGBI)
learning. The implementation of the recommendations of states that even with designated and interested personnel
the Calman Report [3] has led to a shorter, more within the department, the delivery and supervision of
structured training. As less time is spent in the operating high quality training depends on contributions from all
theatre, each trainee may not receive adequate exposure consultant anaesthetists [12]. This is reinforced by the
to, or training in, all areas of airway management. General Medical Council (GMC), which states that all
Increased use of regional techniques and the laryngeal doctors should be willing to contribute to the education
mask airway have meant that trainees have less practice of colleagues, and that those involved in teaching must

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K. R. Stringer et al. Æ Training in airway management Anaesthesia, 2002, 57, pages 967–983
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develop the skills, attitudes and practices of a competent problems. Much work has been done to devise and
teacher [13]. However, most anaesthetists receive little evaluate alternative teaching methods to overcome these
training as teachers and little guidance on how to issues.
improve. Characteristics of good teachers include enthu-
siasm and willingness to teach combined with compe- Didactic teaching
tence and good communication skills [14]. However, for Didactic teaching encompasses classroom-based teaching
complex techniques such as fibreoptic intubation, there and book work. Methods of classroom-based teaching
may be a lack of potential teachers who are themselves may include lectures, tutorials and discussion groups.
trained in their use. When providing training in practical skills, this type of
In this review, we outline the different modalities teaching is a poor substitute for ‘hands-on’ practice.
available for training and assessment in basic airway skills, However, in conjunction with other modalities, it plays
such as laryngoscopy, and more advanced skills, such as an important role. There is a basic core of knowledge that
fibreoptic intubation, cricothyrotomy and tracheostomy. is necessary before a new procedure is attempted, and
classroom teaching or independent reading is important in
this regard. Also, later in training, the discussion of
Anatomy and assessment of the airway
complex clinical problems and controversial issues in
Training in airway management should begin with small group tutorials may be very valuable. A successful
revision of the relevant anatomy. There are many suitable tutorial requires planning, preparation and participation
anatomy texts available and they may be supplemented by both trainee and trainer, and the number of
with teaching using models to help with three-dimen- participants should be small [17].
sional visualisation. Multimedia teaching programmes
have also been designed. Katz et al. [15] demonstrated Video and closed circuit television
the use of video images of the upper airway to familiarise Video display and closed circuit television have been used
students with the anatomy before fibreoptic intubation. to train novices in both standard laryngoscopy and
Difficulties with intubation or management of the fibreoptic intubation.
airway are uncommon but because of their importance, The initial part of laryngoscopic training must include
many attempts have been made to develop predictive observation before ‘hands-on’ practice. The view of the
scores and tests in order to identify patients at risk. It is larynx that the trainee can obtain over the laryngoscop-
important that trainees understand these predictive ist’s shoulder is often limited. The supervisor cannot
methods and also their limitations [16]. observe exactly what the trainee is seeing and there are
significant time restraints during an actual intubation.
Video imaging of intubation may be helpful in famil-
Learning the practical skills
iarising the trainee with the relevant anatomy and is
Competence in management of the airway requires the superior to still photographs or drawings. This may be
mastery of a broad range of skills, from holding an airway of particular use for groups such as paramedics who
and facemask to fibreoptic intubation. This is emphasised have limited opportunity to practice on live patients,
in the competency-based training documents from the but video could also be a useful adjunct for junior
RCA [8, 9]. Some of the skills listed in these documents anaesthetists. Levitan et al. [18] evaluated the use of such
are shown in Table 1. Providing training in these skills on a video on paramedic trainees. The video was used in
live patients poses a number of technical and ethical addition to the standard training of didactic instruction

Table 1 Skills included in the Royal College of Anaesthetists’ competency-based training documents for senior house officers and
specialist registrars years 1–2 [8, 9].

Skills to be learnt in a clinical environment Skills to be learnt in a non-clinical environment with some clinical experience

Basic airway skills with airway and facemask Intubation though a laryngeal mask airway (both blind and fibreoptic)
Use of the laryngeal mask airway Fibreoptic intubation via the nose and mouth
Direct laryngoscopy and tracheal intubation Awake intubation
Rapid sequence induction Use of other airway devices, e.g. Combitube
Use of alternative blades and bougies Elective transtracheal ventilation
Failed intubation drill Retrograde intubation
Placement of double lumen tubes Emergency cricothyrotomy

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Anaesthesia, 2002, 57, pages 967–983 K. R. Stringer et al. Æ Training in airway management
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plus practice on a manikin, and was found to improve ‘Bench’ models

initial success rates of intubation. Models used to develop motor skills. Use of the fibreoptic
Video can also be used to provide feedback to trainees bronchoscope requires the trainee to master complex
by providing a review of their performance. For example, motor skills. Some of the mechanical and visual skills
videotape feedback changed medical students’ perception may be learned on a bench model before practice on a
of how they performed laryngoscopy [19], particularly the patient (Fig. 1). Bainton describes such a device [22].
position of the patient’s head and the passage of time. The ‘Hit the Hole’ device consists of a curved piece of
However, it is a technique more commonly used for acrylic tube down which to pass the fibrescope, and a
reviewing behaviour in complex situations such as number of targets to which the fibrescope tip is sub-
resuscitation of trauma patients and, more recently, in sequently directed. By making the model from trans-
medical simulation. parent acrylic it is possible for an instructor to observe
Closed circuit television (CCTV) can also be a useful the position of the fibrescope through the walls and to
training tool, and its role in teaching fibreoptic intubation provide instruction. Simple home-made devices have
is well established. It allows both the trainee and the also been described [23]. Another example is the
instructor to view the endoscopy simultaneously; thus the ‘Oxford’ Fibreoptic Teaching Box (Pharmabotics Ltd,
instructor can demonstrate the technique to the trainee Nyewood, UK). It consists of a cylindrical, Perspex
and also offer comments and guidance when the trainee box containing five disks with suitably sized holes
performs the procedure. Smith et al. [20] showed that the through which to manipulate the fibrescope. Its
use of CCTV during a graduated training programme usefulness in improving skill in manipulation of the
substantially enhanced the rate of learning for nasotracheal fibrescope has been demonstrated [24]. A more
fibreoptic intubation. They commented that it was sophisticated example is Dexter (Replicant Medical
particularly useful in the early stage of learning, but that Simulators, Wellington, New Zealand), a non-anatom-
care should be taken not to overdo the feedback to avoid ical endoscopic dexterity training system that can be
creating dependence on the instruction, and that feedback varied in its complexity.
should be faded out as the trainee increased in compe- These models can be designed to be technically
tence. Resulting videotapes can also be used for teaching demanding and can improve skills in manipulation of
purposes to introduce new trainees to the technique [21]. the fibrescope, but can they prepare the trainee for the
Advancing technology has allowed the development of anatomy and difficulties encountered in a live patient? In
interactive software packages for training in fibreoptic a recent study, Naik et al. [25] looked at the transfer of
intubation [15]. The role of such packages is well fibreoptic skills learned on a simple model to anaesthe-
established in surgical training and their increased use in tised patients. Using global assessment scales and
anaesthesia seems a natural progression. checklists, they found that residents in anaesthesia who

Figure 1 Models used to develop motor

skills with the fibrescope: (a) simple
home-made model; (b) the ‘Oxford’
Fibreoptic Teaching Box: The Perspex
box contains five disks with holes
through which to manipulate the
fibrescope. Photograph courtesy of
Pharmabotics Ltd (witleyone@aol.com);
(c) the Dexter non-anatomical
endoscopic dexterity training system
(top) complete and (bottom) showing
the internal workings. A series of
navigation pods and pictures are
negotiated and sought with the
fibrescope, the system’s complexity
being varied by the instructor as
required. Photographs courtesy of
Replicant Medical Simulators
(replicant@replicant.co.nz).

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K. R. Stringer et al. Æ Training in airway management Anaesthesia, 2002, 57, pages 967–983
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different equipment available for both cricothyrotomy

and percutaneous tracheostomy.

Models that simulate human anatomy. Manikins or models

that attempt to mimic human anatomy have been used in
training for many years. Their usefulness in surgical
training is well recognised, and a strong potential for
transfer of skills to the operating theatre has been shown
[26]. They also play a core role in teaching skills for basic
life support. Their use for teaching intubation and
investigating new equipment and techniques is also well
established [27, 28]. Howells et al. [29] described the use
of an early manikin for training in tracheal intubation.
They found that despite its limited realism it was a useful
training tool for the novice. Others have adjusted the
manikins to simulate difficult laryngoscopy [27, 28] or
have suggested their use in other than the supine position
[30], thus increasing their training potential.
The use of manikins for training has been keenly
adopted by paramedics, particularly as they have limited
access to teaching on live patients. Such training has been
found to be suitable not only for orotracheal intubation
[31], but also nasotracheal [32] and retrograde intubation
techniques [33]. One study found that practice on a
manikin was as beneficial as practice on animals or in the
operating theatre when training for out-of-hospital
intubations [34]. Their effectiveness in training for
placement of the laryngeal mask airway has also been
shown [35].
Manikins can also be used to acquire fibreoptic skills.
Dykes & Ovassapian [36] described a fibreoptic workshop
solely using models. They found that 35% of attendees
were subsequently able to introduce fibreoptic intubation
into their practice or to improve their success rate. Some
models have been designed solely for this purpose. The
‘Tubes and Trachea’ device described by Bainton [22] is
formed from an anatomical model of the larynx and
tongue enclosed within an acrylic box. The box has two
entry ports through which to introduce the fibrescope.
Figure 1 Continued.
Not only are there manikins for practising tracheal
intubation, but there are now also specific models for
fibreoptic bronchoscopy. These range from a simple,
had received training on such a model performed better plastic tracheobronchial tree to more complex manikins,
than a group receiving didactic training. Clearly, it would e.g. the Scopin II Bronchoboy (Adam, Rouilly Limited,
be inappropriate for these models to form the sole method Sittingbourne, UK). There are also a number of specific
of training, but their use as part of a training programme cricothyrotomy trainers available (Fig. 2b). Practice has
would ease pressures on limited opportunities for training been shown to improve both speed and success of
in the operating theatre, and protect patients from the cricothyrotomy on these manikins [37] and allows the
novice. trainee to become familiar with the procedure before it is
Simple, inexpensive models can also be made and used required in an emergency. However, they can be quite
for training in cricothyrotomy (Fig. 2a). Again, they are expensive.
limited in their ability to mimic human anatomy and The realism and the degree of difficulty of airway
tissues, but may be used to gain familiarity with the manikins vary greatly [38]. There is also a potential for

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Figure 1 Continued.

hold-up of instruments (especially fibreoptic) unless they in airway management as didactic instruction and practice
are well lubricated. However, their fidelity is steadily on a standard manikin in the presence of an instructor
improving. These models avoid the ethical concerns of [39]. Sensors on the manikin assess the position of the
practice on animals, human cadavers and live patients, and head, pressure on the teeth, accuracy of tracheal tube
also the associated risk of infection. The lack of time placement and adequacy of ventilation. However, due to
constraints allows for unhurried and stress-free acquisition the expense of the equipment it was not felt to be cost
of skills, and the models can be used repeatedly. They also effective.
have the potential to be used for unsupervised practice. Advancing technology has allowed the development of
An interactive learning system, with feedback and computerised manikins or patient simulators. These
instruction coming from a ‘sensorized’ manikin head, manikins can be programmed to present a variety of
was found to be as effective for training medical students difficult airway scenarios such as laryngeal oedema or

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Figure 2 Models used for training in

cricothyrotomy and percutaneous
tracheostomy: (a) simple home-made
model; (b) example of a commercially
available model (upper) ready for use
and (lower) open, showing its internal
construction.

laryngospasm. They also allow the management of the However, this type of training poses significant logistical
airway to be viewed in relation to that of other systems, problems and requires close links with a suitable veter-
and may be used in conjunction with a simulated medical inary institution, which may not be readily available. It
environment (see below). Haptic (force-feedback) devices also raises ethical concerns.
have been developed for training in some surgical The use of animal tissue preparations as training tools is
techniques and also bronchoscopy. These devices provide more commonplace. In particular, the use of a pig trachea
a reaction to the trainee’s movement, by producing forces model for training in cricothyrotomy and tracheostomy is
simulating those generated in an actual environment, and well established [45, 46]. This model can be used to attain
allow the trainee to gain a real ‘feel’ for the technique a basic level of skill before performing these potentially
whilst viewing a three-dimensional, computer-generated harmful procedures on live patients.
display. Their effectiveness in training novices in bron-
choscopy has been demonstrated with studies showing Human cadavers
not only improved skill on the device but also transfer of An area that also raises ethical concerns is the practice of
skills to a standard bench model [40] and to patients [41]. airway techniques on the recently deceased. In the past,
The use of training rooms with a range of models, procedures were carried out without the consent of
manikins and airway equipment has been advocated [4] patients or relatives, but this is no longer acceptable. This
but may also be beyond many departments’ resources. practice was most commonly seen in accident and
emergency departments, but it also occurred in intensive
Animals care units and on medical and surgical wards. Both
The disadvantages of plastic models include an unnatural tracheal intubation and invasive techniques such as
‘feel’ and the absence of jaw elasticity, secretions and cricothyrotomy can be taught. More recently, the
reflexes. For this reason, the use of animal models for performance of the intubating laryngeal mask airway
training in practical skills has been investigated. The cat was found to be similar in recent cadavers and paralysed
has upper airway anatomy and reflexes that closely anaesthetised patients, and the cadaver was therefore
resemble a human’s, and anaesthetised cats have been suggested as a model for training in its insertion [47].
advocated as suitable models for teaching laryngoscopy Over recent years, there have been a number of studies
and intubation [42]. Also, practice on anaesthetised assessing the acceptability to the public of this method of
kittens has been found to improve trainees’ technique training. A study in the USA found that > 70% of patients
in neonatal intubation [43]. The anatomy of the pig’s would be happy for procedures to be performed on
larynx and trachea is also remarkably similar to that of the themselves or their relatives, but this decreased to 40% if
human. The anaesthetised pig has been used as a model no prior permission was obtained [48]. Interestingly, these
for performing fibreoptic intubation and was rated as rates were the same for both non-invasive and invasive
more realistic than a manikin in this regard [44]. airway procedures. Olsen et al. [49] looked at actual

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Figure 2 Continued.

consent rates for the performance of cricothyrotomy on a conclude that this type of training is unnecessary for
deceased close relative in the emergency department. most professionals, and that training on manikins and
They found that 39% of families consented whilst 45% anaesthetised patients after informed consent is preferable.
refused. They also noted marked cultural and ethnic For some staff, predominantly those in emergency
differences in rates of consent. departments, the practice on trauma victims with distort-
The British Medical Association and Royal College of ed airway anatomy may be valuable and unobtainable
Nursing have produced guidelines on the practice of elsewhere. At all times the body must be treated with
teaching tracheal intubation on cadavers [50]. They respect and in accordance with the patient’s wishes and

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religious beliefs. Others in the USA feel that the However, in 1984 Cormack & Lehane [61] described a
technique is justified so long as permission is obtained simulation drill for trainees that mimics difficult tracheal
either via advance directive or from the next of kin [51]. intubation. They classified the exposure of the larynx into
For the anaesthetist learning tracheal intubation this type the four, now well-known, grades (Table 2). The drill
of training is unnecessary, as there is ample opportunity to was a method of converting a grade 1 or 2 laryngoscopic
learn in the operating theatre. However, there is less view to a grade 3 view for the purposes of training.
opportunity for practising invasive procedures such as Although an attractive idea, its use has been questioned
cricothyrotomy, though the recent trend towards percu- because of lack of validation of the technique and ethical
taneous tracheostomy in intensive care units, instead of concerns. Goldberg et al. [62] found that by using this
formal surgical procedures, has had an indirect benefit technique they encountered five oesophageal intubations
of exposing both trainee and senior anaesthetists and in 40 patients studied. Although these cases were
intensivists to this technique. uncomplicated they felt that the potential risk to patients
was a serious cause for concern.
Live humans Much of the literature concerning training on live
There is a wide variety of attitudes to teaching airway patients focuses on techniques of fibreoptic intubation.
management skills on anaesthetised patients [5], and many After initial training on manikins, Ovassapian et al. [63]
techniques have been suggested for maximising both recommend learning fibreoptic intubation on awake
patients’ safety, and training potential. These include, on a patients as this may be safer for the patient, technically
simple level, demonstrating and guiding basic mainte- easier, and allow unhurried acquisition of skill. As awake
nance of the airway with a facemask, with or without intubation is often the technique of choice for the
other airway adjuncts, and on a more advanced level, difficult airway, it is important that this technique is
teaching the use of self-supporting devices such as the learnt, but the reluctance of anaesthetists to embark on a
laryngeal mask airway or more invasive procedures such new technique on an awake patient can be understood.
as direct laryngoscopy and fibreoptic intubation. From anecdotal discussions with colleagues, it seems that
Regarding training in basic airway techniques, one general anaesthesia techniques are more common for
study of novices compared the bag and facemask with training in the UK. However, an alternative source of
the laryngeal mask airway. Each participant received awake patients on which to learn fibreoptic skills is the
training in both techniques on two anaesthetised bronchoscopy clinic. It has been suggested that joint
patients. Even following such brief training, success involvement of anaesthetists and physicians in these clinics
rates for insertion of and ventilation with the laryngeal can be beneficial to both parties [64]. As the procedure is
mask airway were 87%, compared with 43% for usually performed under local anaesthesia, it provides
ventilation with the bag and facemask alone [52]. Other similar conditions to those encountered during awake
studies have shown similarly high success rates for fibreoptic intubation. Similar opportunities for laryngos-
inserting the laryngeal mask airway after very little copy are found during nasendoscopy in ENT clinics [65,
training [53–55]. In one study, following only brief 66]. Nasendocopy practice on awake patients in clinic has
instructions and no practice, 94% of paramedics were been found to be as effective a method of training as
successful on the first attempt [55]. Although insertion nasendoscopy practice in anaesthetised patients [66]. In
of the laryngeal mask airway is a comparatively easy the UK, the Norwich Endoscopic Airway Training
technique to learn [56, 57], the potential for prolonged Course is a two-day course that uses the participants of
apnoea and complications such as coughing and laryn- the course as the subjects for awake fibreoptic intubation.
gospasm still exists. To avoid this, one group has The risks are explicitly explained and exclusions may be
suggested placement of the laryngeal mask airway after
tracheal intubation, thus allowing unhurried practice
Table 2 Grading used by Cormack and Lehane to describe
[58]. However, this technique does not allow the trainee laryngoscopic view during a simulation drill for training in
to assess adequacy of ventilation through the device. difficult tracheal intubation [61].
Insertion of the intubating laryngeal mask airway has
been shown to be similarly easy to master with Grade 1 Most of glottis visible; no difficulty anticipated
comparable rates of successful insertion by novices [59, Grade 2 Posterior extremity of the glottis visible; light pressure
will nearly always bring the arytenoids and vocal cords
60]. Because of the relative ease of learning these into view; may be slight difficulty with intubation
techniques, there is little literature on actual methods of Grade 3 Only epiglottis seen; may be fairly severe difficulty with
training. intubation
Grade 4 Cannot expose epiglottis; intubation requires special
Similarly, little literature exists on training methods methods
for direct laryngoscopy and intubation in live humans.

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Anaesthesia, 2002, 57, pages 967–983 K. R. Stringer et al. Æ Training in airway management
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made on medical grounds. In an evaluation of 15 and inhalational anaesthesia have been described and
participants over six months, 85% of participants rated found to be safe [79, 80]. Several studies have compared
the procedure as acceptable and 15% as enjoyable. There fibreoptic intubation with intubation using a Macintosh
were two cases of nosebleeds and one case of paraesthesia laryngoscope. In some of these, the cardiovascular changes
due to hyperventilation. All participants rated this method associated with intubation were more marked in the
of learning as excellent [67]. fibreoptic group [70, 71], raising ethical concerns over
When used in anaesthetised patients, fibreoptic intu- providing training in this method. However, other studies
bation has been shown to be slower than intubation by do not show such a marked effect [68, 69, 81, 82] and the
direct laryngoscopy [68–71], and this potential delay in choice of anaesthetic technique seems to be more
securing the airway influences the anaesthetic techniques important than the method of intubation in this regard.
used. Two basic methods of providing general anaesthesia Pre-oxygenation and moderate hyperventilation can be
for fibreoptic intubation exist: a spontaneously breathing used to prolong the acceptable period of apnoea without
technique and a paralysed apnoeic one. The advantages of hypoxaemia or hypercarbia [68], and mask ventilation can
a spontaneously breathing technique are that adequate be reinstituted when necessary. However, the require-
time is allowed without interruption of ventilation, and ment for ventilation of the lungs during or between
that the rhythmic movement of the tissues is seen as in attempts at laryngoscopy increases the time pressure on
awake patients. Spontaneous ventilation under deep trainees and risks causing hypoxaemia. The airway
inhalational anaesthesia has been successfully demonstrat- endoscopy mask may be especially useful in this regard
ed [72, 73]. However, Smith et al. [74] found that one [83], particularly in children, in whom the time pressures
third of patients suffered significant arterial desaturation are greater [84]. Others have suggested a role for the
when using a deep inhalational technique. They also laryngeal mask airway or other ‘dedicated airways’ [78],
reported coughing, laryngospasm and hypotension. In not only to decrease the duration of apnoea but also to
contrast with other investigators, they studied patients provide a secure airway during laryngoscopy in both
with abnormal airway anatomy. A technique of inter- paralysed and non-paralysed patients [83, 85–88].
mittent thiopental with maintenance of spontaneous The laryngeal mask airway is particularly useful as a
ventilation has also been described and was found to conduit for fibreoptic intubation, for, when the fibre-
provide good conditions for fibreoptic intubation [75]. scope emerges from its distal end, the glottis is usually
Target-controlled infusion of propofol may also have a easily visible and within easy reach [89, 90]. Indeed, the
place [76]. However, whichever method of general RCA has made fibreoptic intubation through the laryn-
anaesthesia is chosen, it results in approximation of the geal mask airway a skill that all trainees must learn,
soft palate, tongue and epiglottis to the posterior although primarily in a non-clinical setting [9]. However,
pharyngeal wall, which may cause the fibreoptic view the laryngeal mask airway can also be used to secure the
to become obscured and the airway to become obstruct- airway during teaching or practising negotiation of
ed. In addition, if a facemask is used it may hinder the the nasal passages and pharynx. One method involves
fibrescope or be difficult to apply without large leaks. The the patient breathing spontaneously through it whilst the
jaw-thrust manoeuvre with oxygen via nasal cannulae fibrescope is passed through a nostril to lie above the
may be successful in maintaining the airway during device’s cuff. At this point, the laryngeal mask airway is
endoscopy [75]. Alternatively, an angle-piece bearing a withdrawn to lie in the oral cavity, allowing access to the
rubber sealed port, through which the fibrescope is larynx [85]. If necessary, the laryngeal mask airway can be
introduced, may be used to connect the facemask to the reinserted and ventilation commenced. This technique
breathing system [77]. Various designs of airway endos- has also been used in paralysed patients with ventilation
copy mask have also been used [73]; in its most recent continuing until the fibrescope lies above the cuff, thus
form the connection to the anaesthetic breathing system is reducing the period of apnoea [88]. In spontaneously
carried away from the face and the fibrescope may be breathing patients, Darling et al. [86] compared a laryn-
introduced through a seal, thus preventing leaks and geal mask airway, modified by splitting it longitudinally,
permitting oral or nasal endoscopy during spontaneous or with the Berman 2 airway. They found that the laryngeal
controlled ventilation. An alternative is to use one of a mask airway performed well as a route for delivering gas
variety of devices to aid control of the airway that also and as a guide for the fibrescope. The split in the laryngeal
allow passage of the fibrescope [78]. mask airway allowed it to be removed from the mouth
Difficulties with oxygenation and the maintenance of an after intubation. Another modification allows nasotrac-
adequate depth of anaesthesia during spontaneous venti- heal fibreoptic intubation via an aperture cut in the
lation have led to greater interest in training on apnoeic posterior aspect of the distal tube of the laryngeal mask
paralysed patients. Again, techniques of both intravenous airway [87]. However, it should be pointed out that any

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K. R. Stringer et al. Æ Training in airway management Anaesthesia, 2002, 57, pages 967–983
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modification of equipment places liability for mishaps training opportunity, allowing trainees to gain experience
directly onto the modifier. in cricothyroid puncture. However, it also poses its own
Fibreoptic intubation via the nasal route has tradition- training difficulties. Learning curves for the technique
ally been thought of as the easier technique to master [64, have been demonstrated [101], yet there is little literature
91], but a recent study showed no advantage or on how best to teach the technique using live patients. A
disadvantage in learning first via the oral or the nasal further consequence is the decreased exposure of surgical
route [92]. Therefore, training can be planned according trainees to formal tracheostomy.
to the availability of patients rather than targeting only
those requiring nasal intubation. However, there is High fidelity platform simulation training
currently no consensus over the need for consent from The use of part-task trainers (body-part manikins and
the patient. Upon reviewing the literature on training in bench models) and simple simulation for airway training,
airway management, it seems that centres are divided, particularly in specific technical skills, is well established.
with some obtaining consent [62, 63, 69] and others not However, the role of high fidelity platform simulation,
[10, 88]. However, a recent survey found that patients i.e. the use of interactive manikins and recreation of the
would like specific information about any non-routine medical environment [102], and a proven basis for its
techniques, including fibreoptic intubation, that are to be added value over other modalities remain unclear. In
performed if the main reason for performing them is for addition, the resources required are enormous. The
teaching or maintaining skills [94]. In the UK, the attraction of high-fidelity simulation is the ability to
AAGBI recommends at least verbal consent for anaes- provide training and practice in the application of basic
thesia, but not for each individual anaesthetic procedure and advanced technical skills that have been learnt in
so long as it is routinely performed [95]. It draws attention other, less sophisticated environments. Once these skills
to the risk of restricted consent whereby the patient may are learned, the trainee must then apply them in real life,
consent for anaesthesia but not for intubation. The occasionally in difficult, time-pressured and rapidly
question is whether techniques such as fibreoptic intuba- changing situations. High-fidelity platform simulation
tion may be considered routine and whether they pose realistically reproduces the conditions under which these
additional risks. Some feel that as the technique of skills are performed and places them into the context of
fibreoptic intubation is safe, and may even have certain real-time decision making. This allows rehearsal and
advantages, consent from the patient is unnecessary [96]. exploration of the factors that may affect the execution of
At a recent meeting of the Difficult Airway Society, this these skills, even within the framework of defined
issue was the topic of considerable debate. It is interesting algorithms, e.g. the ASA difficult airway algorithm. The
that if consent is sought, there can be an unexpectedly importance of these non-technical skills in anaesthesia is
high acceptance rate. One group found that all 25 patients increasingly recognised [103]. Additionally, management
randomised to undergo awake fibreoptic intubation, of infrequent events such as failed intubation with failed
performed solely for training purposes, would repeat the ventilation can be practised without risk to live patients.
procedure [97]. Although largely unproven, practising these skills within
The teaching of more invasive and potentially harmful this context is felt to improve technical, cognitive and
techniques on live patients is controversial. One such team-working performance if similar situations are
technique is that of retrograde intubation. One group encountered in real life [104]. On this basis, this modality
suggests that this can be practised on consenting patients has been incorporated into several airway simulation
presenting for laryngectomy, thus negating the effects of courses in the UK, providing a hybrid of theory, practical
any laryngeal damage caused [98]. They suggest that this skills stations and participation in airway scenarios in a
allows the trainee to gain experience not just of retrograde recreated medical environment (see below).
intubation but also of cricothyroid puncture, an impor-
tant technique for establishing an emergency airway. Structured training programmes
However, full laryngectomy is becoming a less common The haphazard ‘see one, do one’ method of teaching has
procedure due to advances in surgical and non-surgical survived in medicine for many years. However, the
organ preservation strategies [99]. In recent years, percu- benefits of graduated training are now generally recog-
taneous tracheostomy has overtaken formal tracheostomy nised, particularly when learning complex skills such as
as the technique of choice in many intensive care units. fibreoptic intubation. In this form of training, the
Since the technique’s introduction, the proportion of technique is broken up into smaller tasks so that the
intensive care patients receiving tracheostomies has necessary skills can be acquired gradually. This conforms
increased, in one study from 8.5 to 16.8% [100]. This to good educational principles and fulfils the conditions
has several implications. It represents an important required for learning a skill efficiently [63]. A graduated

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Anaesthesia, 2002, 57, pages 967–983 K. R. Stringer et al. Æ Training in airway management
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programme can be in the form of a course or workshop, after 80 attempts, 18% of the trainees needed assistance
or form part of an anaesthetic training scheme. The [109]. Formal learning curves have also been generated
programme will combine several of the teaching methods for fibreoptic intubation. With learning objectives of
described above, bringing them together in a logical intubation within 2 min and > 90% success rate on the
progression. Ovassapian et al. [63] described such a first attempt, Johnson & Roberts [110] found that an
programme for learning fibreoptic intubation using acceptable level of expertise was reached by the tenth
models and live patients. The programme consisted of intubation. With more stringent objectives, Smith et al.
three stages: practice on a model, exposure of the glottis [111] found that after 18 intubations, 70–80% were
in patients recovering from anaesthesia and fibreoptic completed in < 60 s. Using a mono-exponential model,
intubation in awake sedated patients. The evaluation of their learning curve suggests that after 45 intubations (five
the programme was very positive [63] and it performed half-lives) the trainee draws close to their ‘expert’
significantly better than traditional ‘see one, do one’ intubation time. It is clear that whilst these figures may
teaching [105]. However, workshops alone cannot pro- go some way to help with the rational design of training
vide all the experience necessary to intubate the trachea in programmes, numbers alone do not provide a basis on
a patient with a difficult airway. Repeated practice of the which to declare a trainee competent at a procedure.
technique is required [106]. Logbooks are a requirement for all trainees but the
The teaching of a range of airway skills as a non- quality of the information recorded is variable [112].
graduated but specific block within an anaesthesia training Numbers of procedures to which the trainee has been
scheme has also been described [93]. Similar programmes exposed can be seen, but with no information on their
have also been used to improve the airway skills of all success or failure. A recent study attempted to develop
anaesthetists, not only trainees [107]. The advantages of a statistical models to describe the learning of tracheal
mandatory airway block are a more structured approach intubation. The investigators found that a trainee learns
to training and a more uniform exposure of trainees to the about as much from one successful intubation as from 12
required techniques [10]. failed attempts [113]. The necessity of regular practice to
maintain airway skills has also been shown [114].
A simple graphical method has been described by a
Learning curves and assessment
number of authors to visually track a trainee’s progress in
Assessment in anaesthesia traditionally takes the form of mastering technical skills [115, 116]. The result of each
written papers and oral examinations. These are impor- attempt is recorded sequentially on graph paper by filling
tant for assessing trainees’ knowledge and judgement but in a square diagonally upward for a success and diagonally
do not test for competency in practical skills, which is downwards for a failure. This provides an unambiguous
essential for successful clinical performance. The presence record of training but does not necessarily distinguish
of learning curves for practical skills in anaesthesia is well poor performance from routine variability. Various
recognised [27, 28, 30]. From these, estimates of the statistical methods of sequential analysis have also been
number of procedures that must be performed by a used to track performance [117–119]. In CUSUM
trainee in order to reach an acceptable success rate can be analysis, which is widely used in industry, the number
produced. The rapidity of learning depends on the of attempts is plotted against a cumulative score on a
particular skill. Studies show that the learning curve for graph with boundary limits [117]. However, a very large
placement of the laryngeal mask airway is very steep. In number of sequential attempts is needed for some
one study, a 94% success rate was achieved on the first procedures to demonstrate statistically acceptable success
insertion [55], and in others a > 90% success rate was rates.
achieved by the second [54] or third attempt [52, 53]. Another way to assess a trainee’s competence at
This is in contrast to the bag and facemask, which in one practical procedures is via objective assessment. Objec-
study had a success rate of < 50% after 10 attempts [52]. tive structured assessment of technical skill (OSATS)
The learning process for tracheal intubation has also been has been used successfully for surgical trainees to test
studied, with a wide variety of results. Small studies of competency in a range of tasks [120, 121]. Similar tests
medical students have suggested a rapid improvement of have also been developed for skills in anaesthesia such
skills following a short training programme: one study as spinal anaesthesia [122], lumbar epidural anaesthesia
found that 93% of students performed intubation cor- [123] and tracheal intubation [124]. They involve an
rectly on their third attempt [108]; another showed an observer watching the trainee perform a procedure and
80% success rate by the tenth attempt [53]. However, a scoring them according to predefined criteria. These
more formally generated learning curve in anaesthetists tests demonstrate a high level of interobserver reliabil-
suggests a 90% success rate after 57 attempts, and even ity. The principle is used in the objective structured

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K. R. Stringer et al. Æ Training in airway management Anaesthesia, 2002, 57, pages 967–983
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clinical examination (OSCE) in the FRCA examina- reported receiving organised training, again despite the
tion. availability of fibreoptic equipment [11]. Their experi-
The role of medical simulation in the assessment of ence of other airway techniques was also poor, and
anaesthetists is as yet undefined and unvalidated. A recent devices such as the intubating laryngeal mask airway and
review of the literature on assessment of performance equipment for retrograde intubation were reportedly
during simulation found only four papers designed to test rarely available. Another survey found that availability of
validity or reliability of assessment [125]. They concluded structured fibreoptic training varied from 15 to 56%
that the introduction of simulator-based tests would be depending on the region, despite the facilities for such
premature. training being available in more than three quarters of
cases [130]. The situation is better overseas but is still not
ideal. In 1994, Koppel & Reed [10] found that only 27%
The current situation in the UK
of US training programmes required residents to com-
Despite an abundance of literature discussing the impor- plete a dedicated airway block.
tance of training in management of the airway, and a Interestingly, lack of suitably trained personnel did not
wealth of research into how training can best be achieved, appear to be the major factor in the problems highlighted
most surveys of training practice reveal worrying defi- by these surveys; rather, it was a lack of organisation.
ciencies. However, it is often felt that there is a shortage of
A recent survey of trainees in Manchester found that consultants skilled at fibreoptic intubation [64]. Certainly,
only 36% felt confident in the management of the difficult not all anaesthetists in a department may be able to
airway on completion of their training, and that 84% provide fibreoptic training. One survey showed that
rated the organisation of their training as less than although 60% of consultants were happy to perform the
satisfactory [126]. ‘Hands-on’ experience was rated as technique, only 37% taught trainees [126]. If the training
less than satisfactory by 49% for fibreoptic intubation and of future consultants in this area is persistently poor then
by 59% for other difficult airway strategies. we may expect this situation to get worse.
The advantage of structured training in the form of A number of workshops and short courses in airway
designated ‘airway blocks’ or programmes has been management are available in the UK. We have found
discussed. Where these blocks exist they are well received details of 10 that are commercially available (Table 3). Of
[127], but their inclusion into anaesthesia training these, six deal specifically with fibreoptic intubation
schemes has not been widely adopted. A survey of rather than airway management as a whole. They range
training in fibreoptic intubation in the north of England from one to four days in length and vary in the degree of
in 1992 found that despite all 27 departments possessing ‘hands-on’ experience provided. Other short courses are
suitable equipment and trained staff, only one offered provided locally for trainees in their own regions. A one
formal teaching [128]. In South-west Thames in 1991, 11 day, simulator-based difficult airway course is mandatory
of 14 hospitals possessed a fibrescope and personnel skilled for year-3 specialist registrars in North-west Thames
in its use, but only 5 had an established training [131]. This course combines various teaching modalities
programme [129]. Recent surveys show little improve- including the use of manikins, video, role-playing and
ment. In North-east Thames, only 5 of 60 trainees high-fidelity platform simulation. It aims to introduce

Table 3 Commercially available seminars and workshops on airway management in the UK.

No. of Practice on Practice on

days manikins human subjects

Airway Day, Royal College of Anaesthetists, London 1 No No

Birmingham Fibreoptic Skills Development Course 4 Yes Yes
Difficult Airway Management Education (DAME) Symposium, Cardiff 3 Yes No
Difficult Airway Problems, Association of Anaesthetists of Great Britain 1 No No
and Ireland, London
Edinburgh Royal Infirmary Respiratory Endoscopy Course for Anaesthetists 2 Yes Yes
Fibre Optics in Anaesthesia and Intensive Care, Liverpool 3 Yes Yes
Newcastle Fibre Optic Intubation Course 3 Yes Yes
Norwich Endoscopic Airway Training Course 2 Yes Yes
Oxford Fibre Optic Intubation Workshop 2 Yes Yes
Torbay Difficult Airway Course 1 Yes No

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Anaesthesia, 2002, 57, pages 967–983 K. R. Stringer et al. Æ Training in airway management
. ....................................................................................................................................................................................................................

trainees to a range of skills and equipment, and also to 3 Hospital Doctors. Training for the Future. Report of the Working
teach decision making and behavioural skills in a realistic Group on Specialist Medical Training (Calman report). London:
environment. Mastery of all the skills required for Department of Health, 1993.
successful management of the difficult airway cannot be 4 Mason RA. Education and training in airway management.
British Journal of Anaesthesia 1998; 81: 305–7.
taught in such short courses. They may provide a useful
5 Martin PD, Chambers WA. Teaching airway management
introduction to the techniques, but this must then be
on anaesthetised patients. Scottish Medical Journal 1994; 39:
followed up in the trainee’s base hospital. 111–13.
However, in a survey of North-east Thames trainees, 6 Cross J. Airway management – a current training problem?
none of the respondents had visited a workshop, course or Anaesthesia 2000; 55: 515–16.
meeting dealing with management of the difficult airway 7 Royal College of Anaesthetists. Primary and Final Examin-
[11]. In another, larger survey, 41% of registrars had ations for the FRCA. Syllabus. London: Royal College of
attended a fibreoptic intubation course, but with marked Anaesthetists, 1997.
variation of rates between training regions [130]. In the 8 Royal College of Anaesthetists. The CCST in Anaesthesia
US, Koppel & Reed [101] found that even when II. Competency Based Senior House Officer Training and
workshops had been attended, only one third of partici- Assessment. A Manual for Trainees and Trainers. London:
Royal College of Anaesthetists, 2000.
pants subsequently practised the techniques to maintain
9 Royal College of Anaesthetists. The CCST in Anaesthesia
their skills. Similarly, after a two-day workshop in Oxford,
III. Competency Based Specialist Registrar Years 1 and 2
only 35% of attendees performed more fibreoptic intuba- Training and Assessment. A Manual for Trainees and Trainers.
tions than before, although 82% did report an increased London: Royal College of Anaesthetists, 2002.
success rate [132]. Also, few of the participants went on to 10 Koppel JN, Reed AP. Formal instruction in difficult
teach the techniques to others at their base hospital. airway management. A survey of anesthesiology residency
programs. Anesthesiology 1995; 83: 1343–6.
11 Jovanovich S, Clark D, Sampathcumar S. Difficult Airway )
Conclusions Are We Trained Well. Difficult Airway Society Annual
Training in airway management needs to encompass a Meeting, Manchester, 2000.
large range of skills. Not only do technical skills need to 12 Association of Anaesthetists of Great Britain and Ireland.
Consultant: Trainee Working Relationships. London: Associ-
be taught, but so too do decision making and behavioural
ation of Anaesthetists of Great Britain and Ireland, 2001.
skills. There are often problems in providing all the
13 General Medical Council. Good Medical Practice. London:
necessary training on live patients. To help overcome General Medical Council, 2001.
these problems, a variety of training methods has been 14 Shysh AJ, Eagle CJ. The characteristics of excellent clinical
devised and evaluated. These range from providing teachers. Canadian Journal of Anaesthesia 1997; 44: 577–81.
training on a variety of patient substitutes to methods of 15 Katz DB, Pearlman JD, Popitz M, Shorten GD. The
enhancing patients’ safety whilst training takes place. The development of a multimedia teaching program for fiber-
cost and logistics of some of the modalities means that not optic intubation. Journal of Clinical Monitoring 1997; 13:
all methods will be available to all departments. 287–91.
The current situation is unsatisfactory. Management of 16 Yentis SM. Predicting difficult intubation – worthwhile
the airway is central to the practice of anaesthesia, and yet exercise or pointless ritual? Anaesthesia 2002; 57: 105–9.
17 Bullimore DW. Study Skills and Tomorrow’s Doctors.
trainees frequently feel poorly trained in this area.
London: W. Saunders, 1998.
Structured training programmes are desirable but at
18 Levitan RM, Goldman TS, Bryan DA, Shofer F, Herlich
present are not widely available in the UK. A structured A. Training with video imaging improves the initial in-
introduction to the topic is needed early in anaesthesia tubation success rates of paramedic trainees in an operating
training. We strongly recommend that each department room setting. Annals of Emergency Medicine 2001; 37: 46–50.
establishes a formal ‘airway block’ for trainees, and that all 19 Kardash K, Tessler MJ. Videotape feedback in teaching
trainees pass through such a block, at least once. laryngoscopy. Canadian Journal of Anaesthesia 1997; 44:
54–8.
20 Smith JE, Fenner SG, King MJ. Teaching fibreoptic
References nasotracheal intubation with and without closed circuit
1 Cheney FW, Posner KL, Caplan RA. Adverse respiratory television. British Journal of Anaesthesia 1993; 71: 206–11.
events infrequently leading to malpractice suits. A closed 21 Dubin SA, McDonald K. Video display for teaching
claims analysis. Anesthesiology 1991; 75: 932–9. fiberoptic intubations. Anesthesiology; 1989; 71: 167.
2 Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse 22 Bainton CR. Models to facilitate the learning of fiberoptic
respiratory events in anesthesia: a closed claims analysis. technique. International Anesthesiology Clinics 1994; 32:
Anesthesiology 1990; 72: 828–33. 47–55.

 2002 Blackwell Publishing Ltd 979

 13652044, 2002, 10, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2002.02830.x by Readcube (Labtiva Inc.), Wiley Online Library on [20/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
K. R. Stringer et al. Æ Training in airway management Anaesthesia, 2002, 57, pages 967–983
. ....................................................................................................................................................................................................................

23 Colley PS, Freund P. An aid to learning to use the fiber- 38 Stringer KR, Yentis SM. Comparison Of Three Manikins
optic bronchoscope for intubation. Anesthesia and Analgesia Used as Models for Fibreoptic Intubation. Difficult Airway
1997; 85: 464–5. Society Annual Meeting, Oxford, 2001.
24 Popat M, Benham SW, Kapila A, Addy V. Randomised 39 From RP, Pearson KS, Albanese MA, Moyers JR,
Controlled Trial of Learning Fibreoptic Skills on the ‘Oxford’ Sigurdsson SS, Dull DL. Assessment of an interactive
Training Box. Difficult Airway Society Annual Meeting, learning system with ‘sensorized’ manikin head for airway
Edinburgh, 1999. management instruction. Anesthesia and Analgesia 1994; 79:
25 Naik VN, Matsumoto ED, Houston PL, et al. Fiberoptic 136–42.
orotracheal intubation on anesthetised patients. Do 40 Colt HG, Crawford SW, Galbraith O. Virtual reality
manipulation skills learned on a simple model transfer into bronchoscopy simulation. A revolution in procedural
the operating room? Anesthesiology 2001; 95: 343–8. training. Chest 2001; 120: 1333–9.
26 Anastakis DJ, Regehr G, Reznick RK, et al. Assessment of 41 Ost D, de Rosiers A, Britt EJ, Fein AM, Lesser ML, Metha
technical skills transfer from the bench training model to the AC. Assessment of a bronchoscopy simulator. American
human model. American Journal of Surgery 1999; 177: 167–70. Journal of Respiratory and Critical Care Medicine 2001; 164:
27 Dyson A, Harris J, Bhatia K. Rapidity and accuracy of 2248–55.
tracheal intubation in a mannequin: comparison of the 42 Calderwood HW, Ravin MB. The cat as a teaching model
fibreoptic with the Bullard laryngoscope. British Journal of for endotracheal intubation. Anesthesia and Analgesia 1972;
Anaesthesia 1990; 65: 268–70. 51: 258–9.
28 Hodges UM, O’Flaherty D, Adams AP. Tracheal intuba- 43 Sankaran K, Yadlapalli J, Zakhary GX. Evaluation of a
tion in a mannikin: comparison of the Belscope with the teaching method for endotracheal intubation in neonates.
Macintosh laryngoscope. British Journal of Anaesthesia 1993; Annals of the Royal College of Physicians and Surgeons of
71: 905–7. Canada 1985; 18: 135–6.
29 Howells TH, Emery FM, Twentyman JEC. Endotracheal 44 Forbes RB, Murray DJ, Albanese MA. Evaluation of an
intubation training using a simulator. An evaluation of the animal model for teaching fibreoptic tracheal intubation.
Laerdal adult intubation model in the teaching of endo- Canadian Journal of Anaesthesia 1989; 36: 141–4.
tracheal intubation. British Journal of Anaesthesia 1973; 45: 45 Hedges J, Toomey T, Adkins W. The Cambridge surgical
400–2. training device for cricothyrotomy and tracheostomy
30 Nathanson MH, Gajraj NM, Newson CD. Tracheal in- techniques. Journal of British Association of Immediate Care
tubation in a manikin: comparison of supine and left lateral 1989; 12: 11–12.
positions. British Journal of Anaesthesia 1994; 73: 690–1. 46 Gardiner Q, White PS, Carson D, Shearer A, Frizelle F,
31 Stratton SJ, Kane G, Gunter CS, et al. Prospective study of Dunkley P. Technique training: endoscopic percutaneous
manikin-only versus manikin and human subject endo- tracheostomy. British Journal of Anaesthesia 1998; 81: 401–3.
tracheal intubation training of paramedics. Annals of 47 Keller C, Brimacombe J. The intubating laryngeal mask
Emergency Medicine 1991; 20: 1314–18. airway in fresh cadavers vs paralysed anesthetised patients.
32 March JA, Farrow JL, Brown LH, Dunn KA, Perkins PK. Canadian Journal of Anaesthesia 1999; 46: 1067–9.
A breathing manikin model for teaching nasotracheal in- 48 Manifold CA, Storrow A, Rodgers K. Patient and family
tubation to EMS professionals. Prehospital Emergency Care attitudes regarding the practice of procedures on the newly
1997; 1: 269–72. deceased. Academic Emergency Medicine 1999; 6: 110–15.
33 van Stralen DW, Rogers M, Perkin RM, Fea S. Retro- 49 Olsen J, Spilger S, Windisch T. Feasibility of obtaining
grade intubation training using a mannequin. American family consent for teaching cricothyrotomy on the newly
Journal of Emergency Medicine 1995; 13: 50–2. dead in the emergency department. Annals of Emergency
34 Stewart RD, Paris PM, Pelton GH, Garretson D. Effect of Medicine 1995; 25: 660–5.
varied training techniques on field endotracheal intubation 50 British Medical Association. Tracheal Intubation of the Re-
success rates. Annals of Emergency Medicine 1984; 13: 1032– cently Deceased Patients for Teaching Purposes. A. Statement
6. from the BMA and RCN. London: British Medical Asso-
35 Roberts I, Allsop P, Dickinson M, Curry P, Eastwick- ciation, 1997.
Field P, Eyre G. Airway management training using the 51 Orlowski JP, Kanoti GA, Mehlman MJ. The ethics of using
laryngeal mask airway: a comparison of two different newly dead patients for teaching and practicing intubation
training programmes. Resuscitation 1997; 33: 211–14. techniques. New England Journal of Medicine 1988; 319: 439–41.
36 Dykes MHM, Ovassapian A. Dissemination of fibreoptic 52 Alexander R, Hodgson P, Lomax D, Bullen C. A com-
airway endoscopy skills by means of a workshop utilizing parison of the laryngeal mask airway and Guedel airway,
models. British Journal of Anaesthesia 1989; 63: 595–7. bag and facemask for manual ventilation following formal
37 Prabhu AJ, Wong DT, Correa RK, Lanzieri M, Imasogie training. Anaesthesia 1993; 48: 231–4.
N, Chung F. Training Improves Cricothyroidotomy Success 53 Davies PRF, Tighe SQM, Greenslade GL, Evans GH.
Rate. Difficult Airway Society Annual Meeting, Oxford, Laryngeal mask airway and tracheal tube insertion by
2001. unskilled personnel. Lancet 1990; 336: 977–9.

980  2002 Blackwell Publishing Ltd

 13652044, 2002, 10, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2002.02830.x by Readcube (Labtiva Inc.), Wiley Online Library on [20/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia, 2002, 57, pages 967–983 K. R. Stringer et al. Æ Training in airway management
. ....................................................................................................................................................................................................................

54 Baskett PJF (co-ordinator). The use of the laryngeal mask anaesthetic technique to aid training. Anaesthesia 1988; 43:
airway by nurses during cardiopulmonary resuscitation. 410–13.
Results of a multicentre trial. Anaesthesia 1994; 49: 3–7. 73 Erb T, Hampl KF, Schurch M, Kern CG, Marsch SCU.
55 Pennant JH, Walker MB. Comparison of the endotracheal Teaching the use of fibreoptic intubation in anesthetized,
tube and laryngeal mask in airway management by para- spontaneously breathing patients. Anesthesia and Analgesia
medic personnel. Anesthesia and Analgesia 1992; 74: 531–4. 1999; 89: 1292–5.
56 Martin PD, Cyna AM, Hunter WAH, Henry J, Ramayya 74 Smith M, Calder I, Crockard A, Isert P, Nicol ME.
GP. Training nursing staff in airway management for Oxygen saturation and cardiovascular changes during
resuscitation. A clinical comparison of the facemask and fibreoptic intubation under general anaesthesia. Anaesthesia
laryngeal mask. Anaesthesia 1993; 48: 33–7. 1992; 47: 158–61.
57 Reinhart DJ, Simmons G. Comparison of placement of the 75 Yentis SM, Jankowski S, Gregory IC. Intermittent thio-
laryngeal mask airway with endotracheal tube by para- pentone for teaching fibreoptic nasotracheal intubation.
medics and respiratory therapists. Annals of Emergency Anaesthesia 1993; 48: 340–2.
Medicine 1994; 24: 260–3. 76 Clarke SG, Dunsire MF. Laryngoscopy Conditions in Spon-
58 Asai T, Shingu K. Training method for placement of the taneously Breathing Patients: An Incremental Step-Up Regimen
laryngeal mask. Anaesthesia 1999; 54: 811. Using Propofol by Target Controlled Infusion. Difficult Airway
59 Burgoyne L, Cyna A. Laryngeal mask vs intubating Society Annual Meeting, Oxford, 2001.
laryngeal mask: insertion and ventilation by inexperienced 77 Greenhough SG, Vaughan RS. Fibreoptic instruments and
resuscitators. Anaesthesia and Intensive Care 2001; 29: 604–8. tracheal intubation in adults and children. In: Latto IP,
60 Choyce A, Avidan MS, Shariff A, Del Aguila M, Radcliffe Vaughan RS, eds. Difficulties in Tracheal Intubation, 2nd edn.
JJ, Chan T. A comparison of the intubating and standard London: W.B. Saunders, 1997.
laryngeal mask airways for airway management by inex- 78 Charters P, O’Sullivan E. The ‘dedicated airway’: a review
perienced personnel. Anaesthesia 2001; 56: 350–69. of the concept and an update of current practice. Anaes-
61 Cormack RS, Lehane J. Difficult tracheal intubation in thesia 1999; 54: 778–86.
obstetrics. Anaesthesia 1984; 39: 1105–11. 79 Schaefer HG, Marsch SCU, Staender S. Fibreoptic
62 Goldberg JS, Bernard AC, Marks RJ, Sladen RN. Simu- intubation under general anaesthesia need not be associated
lation technique for difficult intubation: teaching tool or with hypoxia and hypotension. Anaesthesia 1992; 47:
new hazard? Journal of Clinical Anesthesia 1990; 2: 21–6. 812–13.
63 Ovassapian A, Dykes MHM, Golmon ME. A training 80 Schaefer HG, Marsch SCU, Strebel SP, Drewe J.
programme for fibreoptic nasotracheal intubation. Use of Cardiovascular effects of fibreoptic oral intubation. A
model and live patients. Anaesthesia 1983; 38: 795–8. comparison of a total intravenous technique and a balanced
64 Mason RA. Learning fibreoptic intubation: fundamental volatile technique. Anaesthesia 1992; 47: 1034–6.
problems. Anaesthesia 1992; 47: 729–31. 81 Smith JE, Mackenzie AA, Sanghera SS, Scott-Knight
65 Peskett MJ. Training in fibreoptic intubation. British Journal VCE. Cardiovascular effects of fibrescope-guided naso-
of Anaesthesia 1992; 69: 331. tracheal intubation. Anaesthesia 1989; 44: 907–10.
66 Burke DP, Osborn NA, Smith JE, Reid AP. Learning 82 Hartley M, Morris S, Vaughan RS. Teaching fibreoptic
fibreoptic skills in ear, nose and throat clinics. Anaesthesia intubation. Effect of alfentanil on the haemodynamic
1996; 51: 81–3. response. Anaesthesia 1994; 49: 335–7.
67 An evaluation of the Norwich Endoscopic Airway training 83 Aoyama K, Yasunaga E, Takenaka I, Kadoya T, Sata T,
course (accessed 11 April 2002). www.neat-course.org.uk/ Shigematsu A. Positive pressure ventilation during fibre-
page11.html optic intubation: comparison of the laryngeal mask airway,
68 Cole AFD, Mallon JS, Rolbin SH, Ananthanarayan C. intubating laryngeal mask and endoscopy mask techniques.
Fiberoptic intubation using anesthetized, paralyzed, apneic British Journal of Anaesthesia 2002; 88: 246–54.
patients. Results of a resident training program. Anesthesi- 84 Erb T, Marsch SCU, Hampl KF, Frei FJ. Teaching the use
ology 1996; 84: 1101–6. of fiberoptic intubation for children older than two years of
69 Schaefer HG, Marsch SCU, Keller HL, Strebel S, Anselmi age. Anesthesia and Analgesia 1997; 85: 1037–41.
L, Drewe J. Teaching fibreoptic intubation in anaesthetised 85 Alexander R, Moore C. The laryngeal mask airway and
patients. Anaesthesia 1994; 49: 331–4. training in nasotracheal intubation. Anaesthesia 1993; 48:
70 Smith JE. Heart rate and arterial pressure changes during 350–1.
fibreoptic tracheal intubation under general anaesthesia. 86 Darling JR, Keohane M, Murray JM. A split laryngeal
Anaesthesia 1988; 43: 629–32. mask as an aid to training in fibreoptic tracheal intubation.
71 Smith JE, Mackenzie AA, Scott-Knight VCE. Comparison A comparison with the Berman II intubating airway.
of two methods of fibrescope-guided tracheal intubation. Anaesthesia 1993; 48: 1079–82.
British Journal of Anaesthesia 1991; 66: 546–50. 87 Marjot R, Cook TM, Baylis R. Teaching fibreoptic
72 Coe PA, King TA, Towey RM. Teaching guided nasotracheal intubation via the laryngeal mask airway.
fibreoptic nasotracheal intubation. An assessment of an Anaesthesia 1996; 51: 511–12.

 2002 Blackwell Publishing Ltd 981

 13652044, 2002, 10, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2002.02830.x by Readcube (Labtiva Inc.), Wiley Online Library on [20/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
K. R. Stringer et al. Æ Training in airway management Anaesthesia, 2002, 57, pages 967–983
. ....................................................................................................................................................................................................................

88 Osborn NA, Jackson APF, Smith JE. The laryngeal mask 106 Koppel JN, Reed AP. Are postgraduate fiberoptic-guided
airway as an aid to training in fibreoptic nasotracheal intubation workshops accomplishing their goals? Anesthesia
endoscopy. Anaesthesia 1998; 53: 1080–3. and Analgesia 1994; 78: S216.
89 Brimacombe J, Newell S, Swainston R, Thompson J. A 107 Parmet JL, Metz S, Miller F, Pharo G, Rosenberg H.
potential new technique for awake fibreoptic bronchos- Airway awareness week: a method of teaching alternative
copy – use of the laryngeal mask airway. Medical Journal of airway techniques. Anesthesiology 1995; 83: A1123.
Australia 1992; 156: 876–7. 108 O’Flaherty D, Adams AP. Endotracheal intubation skills of
90 Brimacombe J, Tucker P, Simons S. The laryngeal mask medial students. Journal of the Royal Society of Medicine 1992;
airway for awake diagnostic bronchoscopy. A retrospective 85: 603–4.
study of 200 consecutive patients. European Journal of 109 Konrad C, Schupfer G, Wietlisbach M, Gerber H.
Anaesthesiology 1995; 12: 357–61. Learning manual skills in anesthesiology: is there a
91 Vaughan RS. Training in fibreoptic laryngoscopy. British recommended number of cases for anesthetic procedures?
Journal of Anaesthesia 1991; 66: 538–40. Anesthesia and Analgesia 1998; 86: 635–9.
92 Smith JE, Jackson APF. Learning fibreoptic endoscopy. 110 Johnson C, Roberts JT. Clinical competence in the
Nasotracheal or orotracheal intubations first? Anaesthesia performance of fiberoptic laryngoscopy and endotracheal
2000; 55: 1072–5. intubation: a study of resident instruction. Journal of Clinical
93 Cooper SD, Benumof JL. Teaching the management of Anesthesia 1989; 1: 344–9.
the difficult airway: the UCSD airway rotation. Anesthesi- 111 Smith JE, Jackson APF, Hurdley J, Clifton PJM. Learning
ology 1994; 81: A1241. curves for fibreoptic nasotracheal intubation when using
94 Bray JK, Yentis SM. Attitudes of patients and anaesthetists the endoscopic video camera. Anaesthesia 1997; 52: 101–6.
to informed consent for specialist airway techniques. 112 Strang TI. Anaesthetic log books. How are they being
Anaesthesia 2002; in press. used? Anaesthesia 1993; 48: 69–74.
95 Association of Anaesthetists of Great Britain and Ireland. 113 Plummer JL, Owen H. Learning endotracheal intubation
Information and Consent for Anaesthesia. London: Association in a clinical skills learning center: a quantitative study.
of Anaesthetists of Great Britain and Ireland, 1999. Anesthesia and Analgesia 2001; 93: 656–62.
96 Allen G, Murray WB. Teaching airway management 114 Kovacs G, Bullock G, Ackroyd-Stolarz S, Cain E, Petrie
skills: what about patient consent? Anesthesiology 1996; 85: D. A randomized controlled trial on the effect of educa-
437–8. tional interventions in promoting airway management
97 Marsch SCU, Aeschbach A, Schaefer HG. Teaching awake skill maintenance. Annals of Emergency Medicine 2000; 36:
fibreoptic intubation in patients without specific medical 301–9.
indication. Anesthesiology 1995; 83: A1014. 115 Wilson ME. Assessing intravenous cannulation and tracheal
98 Guggenberger H, Lenz G. Training in retrograde intuba- intubation training. Anaesthesia 1991; 46: 578–9.
tion. Anesthesiology 1988; 69: 292. 116 Lawler PG, Patla VR, Garcia E, Puttick N. Assessment of
99 Wolf GT. Options for preserving the larynx in patients training in anaesthesia and related skills. Anaesthesia 1991;
with advanced laryngeal and hypopharyngeal cancer. Ear, 46: 597.
Nose and Throat Journal 2001; 80: 897–901. 117 Kestin IG. A statistical approach to measuring the
100 Simpson TP, Day CJE, Jewkes CF, Manara AR. The competence of anaesthetic trainees at practical procedures.
impact of percutaneous tracheostomy on intensive care British Journal of Anaesthesia 1995; 75: 805–9.
unit practice and training. Anaesthesia 1999; 54: 186–9. 118 Sneyd JR. Using sequential testing to assess skill at tracheal
101 Powell DM, Price PD, Forrest LA. Review of percuta- intubation. Anesthesiology 1994; 81: A1242.
neous tracheostomy. Laryngoscope 1998; 108: 170–7. 119 Harrison MJ. Tracking the early acquisition of skills by
102 Gaba DM, DeAnda A. A comprehensive anesthesia trainees. Anaesthesia 2001; 56: 988–1002.
simulation environment. Re-creating the operating 120 Martin JA, Regehr G, Reznick R, et al. Objective struc-
room for research and training. Anesthesiology 1988; 69: tured assessment of technical skill (OSATS) for surgical
387–94. residents. British Journal of Surgery 1997; 84: 273–8.
103 Fletcher GCL, McGeorge P, Flin RH, Glavin RJ, Maran 121 Reznick R, Regehr G, MacRae H, Martin J, McCulloch
NJ. The role of non-technical skills in anaesthesia: a review W. Testing technical skill via an innovative ‘bench station’
of current literature. British Journal of Anaesthesia 2002; 88: examination. American Journal of Surgery 1996; 172: 226–30.
418–29. 122 Sivarajan M, Miller E, Hardy C, et al. Objective evaluation
104 Chopra V, Gesink BJ, de Jong J, Bovill JG, Spierdijk J, of clinical performance and correlation with knowledge.
Brand R. Does training on an anaesthesia simulator lead to Anesthesia and Analgesia 1984; 63: 603–7.
improvement in performance? British Journal of Anaesthesia 123 Sivarajan M, Lane PE, Miller EV, et al. Performance
1994; 73: 293–7. evaluation: continuous lumbar epidural anesthesia skill test.
105 Ovassapian A, Yelich SJ, Dykes MHM, Golman ME. Anesthesia and Analgesia 1981; 60: 543–7.
Learning fibreoptic intubation: use of simulators 124 O’Connor HM, McGraw RC. Clinical skills training:
v. traditional teaching. British Journal of Anaesthesia 1988; developing objective assessment instruments. Medical
61: 217–20. Education 1997; 31: 359–63.

982  2002 Blackwell Publishing Ltd

 13652044, 2002, 10, Downloaded from https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1046/j.1365-2044.2002.02830.x by Readcube (Labtiva Inc.), Wiley Online Library on [20/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Anaesthesia, 2002, 57, pages 967–983 K. R. Stringer et al. Æ Training in airway management
. ....................................................................................................................................................................................................................

125 Byrne AJ, Greaves JD. Assessment instruments used during 129 Telford RJ, Rawle PR. Training in fibreoptic laryngos-
anaesthetic simulation: review of published studies. British copy. British Journal of Anaesthesia 1991; 67: 503.
Journal of Anaesthesia 2001; 86: 445–50. 130 Danha RF, Benham S. Training in Fibreoptic Intubation
126 MacKinnon RJ, Dobson A. A Survey of the Training Provi- Survey. Difficult Airway Society Annual Meeting, Oxford,
sion at Three Teaching Hospital Trusts for the Management of 2001.
Difficult Airways. Difficult Airway Society Annual Meeting, 131 Stringer K, Yentis S, Wyner J, Bajenov S, Bloch M.
Manchester, 2000. Development of a Simulator-Based Difficult Airway Course.
127 Smith HL. Training in difficult airway management. International Meeting on Medical Simulation, Santa Clara,
Anaesthesia 2001; 56: 381. California, 2002.
128 Wood PR, Dresner M, Lawler PGP. Training in fibreoptic 132 Vanarase MY, Popat M, Benham S, Kapila A. Fibreoptic
tracheal intubation in the north of England. British Journal Intubation Workshops – Are They Useful? Difficult Airway
of Anaesthesia 1992; 69: 202–3. Society Annual Meeting, Oxford, 2001.

 2002 Blackwell Publishing Ltd 983