In 1998, Rosemary Mason's editorial highlighted difficulties in providing advanced training in airway management for United Kingdom (UK) anaesthetists and proposed a blueprint for improving training [1]. She described reducing opportunities to practise airway skills, due to shortened training and competition from new airway devices. Her solutions focused on local delivery of airway training, including adoption of and commitment to using simple guidelines/algorithms, concentration of training on the techniques within those guidelines, off-patient teaching and establishing dedicated airway training rooms in each anaesthetic department. This editorial reflects on the evolution of this issue since 1998 and offers thoughts on solutions, based around the implementation of the UK Difficult Airway Society (DAS) guidelines.

Mason called for the use of simple guidelines. The DAS guidelines for management of the difficult airway, incorporating three algorithms for specific clinical scenarios, were published in Anaesthesia in July 2004 [2]. The algorithms require optimal intubation technique, use of the Classic laryngeal mask airway (LMATM), intubating LMA (ILMA), ProSeal LMA, and cannula or surgical cricothyroidotomy. Their publication sparked considerable comment about the need for guidelines, the guidelines themselves [3–5] and the organisation of UK anaesthetic airway training [6]. Taylor commented that ‘(it is a) fundamental duty of all practising anaesthetists both to train others and to improve our own airway skills at every opportunity throughout our careers’. Asai and Latto responded first that ‘the weakness of algorithms has been that many anaesthetists are unable to implement the technical components, particularly the more complex procedures’ and ‘it is time to tackle the task of managing the difficult airway in a more organised way’[7].

Might the DAS guidelines be part of the solution to this problem? The use of guidelines in general has been shown in meta-analysis to improve outcome [8]. While not everyone agrees with these LMA-based guidelines they are consensus-driven, evidence-based and pragmatic. They include generally available equipment, incorporate transferable skills and provide step-by-step algorithms. As such they are a reasonable starting point: there are few credible alternatives.

The problem

  1. Top of page
  2. The problem
  3. Solutions
  4. Potential conflicts of interest
  5. References

In the last 7 years the problems described by Rosemary Mason have increased and further concerns have been raised over competence.

Trainees now do fewer cases and their work pattern has moved away from elective towards emergency work. Mason highlighted the reduction in time spent in theatre during Calman training [1]. ‘Achieving a Balance’ and the European Working Time Directive have exacerbated the problem. Some current trainees may anaesthetise fewer cases before completing training than a Senior House Officer (SHO) did two decades ago (Dr C. Johnson, Southmead Hospital, personal communication). Underwood and MacIndoe documented a 20% decrease in trainee caseload in the period 1996–2004 [9]. Notably, the proportion of SHO-anaesthetised cases occurring at night (presumably unsupervised) increased and although Specialist Registrars (SpRs) anaesthetised more obstetric cases, most were under regional anaesthesia. The 2003 NCEPOD report ‘Who Operates When II’ reported that 38% of trainees' cases were non-elective and 30% of SHO ‘solo’ cases were out-of-hours emergencies [10].

Trainees now also intubate fewer patients. In 2003 Moore and McLeod reported that novice trainees intubate an average of one patient per working day in their first 3 months of training, but fewer than one rapid sequence induction (RSI) intubation per week [11]. Increasing use of laryngeal masks is clearly one explanation and new airway equipment such as the ProSeal LMA (PLMA) may further reduce tracheal intubation. In 2003, an estimated two-thirds of all UK anaesthetics are administered via a supraglottic airway. In 1998, the Classic laryngeal mask airway had been available for 8 years and perhaps one might think that little would have changed since then, but Yarrow reported a 30% reduction in the number of patients intubated in a district general hospital (DGH) between 1995 and 2001 [12]. Intubations during ‘working hours’ in ASA 1–2 patients reduced by more than 40% but remained stable in sicker patients and outside office hours. Thus, the opportunity for intubation practice has diminished while the number of intubations performed during ‘at risk’ times has not fallen. Even those opportunities that exist are often missed; a 2005 survey reported that only 18% of intubations occur in a training setting [13].

To compound the problem, it is trainees who manage many unanticipated airway problems. In the most recent Confidential Enquiry into Maternal and Child Health (CEMACH) report, all three deaths from unrecognised oesophageal intubation occurred when an ‘SHO without immediate backup’ administered anaesthesia [14]. Although most surgical cases take place during office hours, a disproportionate number of failed intubations and airway emergencies occur out of hours, during emergencies and in the hands of trainees working alone [15]. The incidence is unknown, but many estimates are likely to be too low. In 2000, we found that, during RSI, 45% of anaesthetists had experienced failed intubation and 28% regurgitation [16]. However, a disproportionate number of events were reported by first-year trainees. So, logically, any anaesthetist considered competent to anaesthetise alone should be equipped to make a confident, effective attempt at detecting and managing airway emergencies. This implies exposure to, and a degree of mastery of, techniques required for unexpected difficult intubation, failed intubation during RSI and failed ventilation; furthermore, all should have been accomplished within the first year of a trainee's anaesthetic career.

The introduction of new equipment at an accelerating rate over the last decade may also compromise training. Increasing numbers of devices and techniques for airway management lead both to confusion when decisions are required, and dilution in core skills training. Greaves reports that most clinical skills have a fairly consistent learning curve of approximately 30 attempts [17]. Such learning curves have been reported for use of all laryngeal mask airway types [18–20], with a longer learning period for cricothyroidotomy [21].

Is there really a problem? Training is one thing, performance another. Concerns have been raised over a perceived increase in airway complications in UK anaesthetic practice, particularly in obstetric anaesthesia [9, 14, 22, 23]. In the latest CEMACH report, anaesthesia-related deaths increased, and all were associated with general anaesthesia [14]. Worse, when complications occur, their management may be poor. Rahman reported suboptimal management in 50% of 16 failed obstetric intubations [24]. Kee commented ‘The current (CEMACH) report should be an impetus for all departments to examine not only their training programmes but also their policies for supervision and implementation of guidelines. This should extend to subspecialties other than obstetrics’[23]. At the last Difficult Airway Society meeting a host of concerning data was presented. Space does not allow detail, but a series of abstracts reported widespread ignorance, inexperience or even incompetence in the use of intermediate and rescue equipment for managing the difficult airway. The failings affected all grades of anaesthetist.

Two further changes have occurred in the last 8 years. Firstly, patients are changing. Increasingly complex patients are accepted for surgery, while the incidence of obesity rises at epidemic pace and the proportion of patients treated as emergencies has increased by up to 10% per year for several years. It is no surprise that sicker, older, fatter patients undergoing emergency surgery pose greater airway challenges. Consultant expertise may not be immediately available for many emergencies. Secondly, patient expectations are also changing. Previously it was tacitly considered acceptable to learn new techniques on elective patients. As societal and patient expectations change this becomes ever less acceptable [25–27]. Patients expect to be informed and consent sought when non-routine techniques are performed on them, even for teaching purposes [27]. These pressures, and increased time constraints, further dilute opportunities for training in airway management. Recent comment on training in regional anaesthesia suggested that patient consent was mandatory, that the trainee ‘must be deemed capable of performing the task safely’ and suggested that only those with ‘future need to use techniques should be trained in specialist techniques’[28]. This last consideration differs fundamentally between regional anaesthesia and airway management. Regional techniques are largely elective procedures that not every anaesthetist need master. In contrast, when required, emergency airway management is potentially life-saving and needed instantaneously. All anaesthetists therefore have a responsibility to know, and be trained in, the techniques which they will use to manage an airway emergency, even though the need may never arise.

All these factors combine to create latent risks to patients and trainee anaesthetists.

The latent risk to patients arises from incompletely trained anaesthetists. The risk to trainees includes being exposed to situations which they feel, or are, unable to handle safely, and the possibility of litigation. Nowadays we may be exposed to multiple prejudice, professional or public censure and criminal prosecution. If clinical performance is considered unacceptably poor it constitutes ‘gross negligence’. The prospect of manslaughter charges and imprisonment of doctors has precedent [29], as does the possibility of corporate conviction if trainees are inadequately supervised [30].


  1. Top of page
  2. The problem
  3. Solutions
  4. Potential conflicts of interest
  5. References

Mason offered a series of potential solutions; how have we progressed?

Some suggest limiting the use of laryngeal mask airways [31, 32] and routinely worsening the view at laryngoscopy view to allow trainees to practise difficult intubation [33, 34]. While superficially appealing, this risks using the patient as a training manikin. Both plans would increase muscle relaxant usage and the number of intubations performed. Neither are trivial procedures and, particularly when difficult, may cause significant complications [35]. These plans are therefore outmoded, and in the absence of informed patient consent, unethical.

So if these are not the solutions, what options are there? The assumption that airway training will occur by ‘osmosis’ or apprenticeship is clearly no longer valid. National and regional training courses, while laudable, are unable to reach a large enough number of anaesthetists and often focus on fibreoptic intubation and advanced skills. These therefore do not provide the solution to the identified problems. There is a need for agreement over which skills are ‘core’ and which are outmoded or specialised. We can then achieve locally delivered, appropriate, repeatable training in core airway skills in every UK anaesthetic department.

The DAS guidelines could be used to define the core skills. The Royal College of Anaesthetists (RCA) syllabus for competency-based training includes airway skills to be practised either on patients or on manikins [36, 37]. It is notable that the SHO competency includes ‘intubation up to grade II Cormack-Lehane’ and ‘use of a gum elastic bougie’, while the SpR syllabus includes ‘low skill fibreoptic intubation via the laryngeal mask’ and ‘fibreoptic intubation’. The ILMA is not mentioned. These syllabuses were written before publication of the DAS guidelines. When revised, perhaps the RCA might endorse the guidelines, using them to define core skills in airway management more clearly. In addition, the RCA could ensure that knowledge and performance of these skills are regularly tested in professional examinations, in a similar manner to cardiac arrest algorithms.

Training methods need to change with the times. High fidelity simulators are available in several sites throughout the UK and 90% of trainees support simulation in training [38]. The RCA believes that simulation training should increase, but it is costly both in terms of time and resources and is not currently part of routine UK training [38]. Smaller scale airway manikins, previously of limited quality, have improved considerably and now mimic clinical performance and anatomical ‘feel’ accurately [39, 40]. These offer an intermediate solution.

If off-patient training is to be effective, suitable equipment needs to be purchased and routinely available for training and practice. The evidence is that it is rarely available [41]. In 2004, only 15% of hospitals offered out-of-theatre airway training in a dedicated teaching room [42]. All hospitals with these rooms considered them either useful or essential.

Locally based training should be achievable with the following framework.

  • • 
    Adoption of an airway algorithm as departmental policy. The DAS guidelines are the logical choice at present.
  • • 
    Agreement on the equipment required to fulfil the algorithm.
  • • 
    Purchase of enough equipment to allow training and to ensure rapid availability clinically.
  • • 
    A training programme for all anaesthetists, and anaesthetic assistants, in the techniques required to implement the guidelines (e.g. workshops on manikins/simulators in the usual theatre environment). Repetition at intervals of no more than 6 months to train new recruits and ensure skill retention.
  • • 
    Reinforcement of the learned skills with theatre-based training.
  • • 
    An anaesthesia skills room equipped with sufficient educational material and practice equipment to allow tutored and self-directed training.
  • • 
    Audit of the process and impact on skill acquisition of such programmes.

Many of these elements were proposed by Mason and, whereas some departments have similar models in place [43, 44], there is limited evidence of widespread progress and the message seems important enough to repeat. Importantly, the framework should only be a starting point to further training, performed on manikins and on targeted operating lists in consenting patients. The impact of such off-patient training on clinical learning curves has not been examined, but limited evidence suggests that it is beneficial [45]. Such plans will certainly not eliminate the need for trainees to ‘learn’ or ‘practise’ on patients, but they may allow them to perform with greater confidence and competence.

Taylor and colleagues expressed the view that airway management involves skill acquisition and reinforcement throughout an anaesthetist's career. While this is self-evident to most active clinicians, it is also likely that simple, potentially life-saving techniques can be taught and learned in a local environment, to the benefit of patient and anaesthetist.

Potential conflicts of interest

  1. Top of page
  2. The problem
  3. Solutions
  4. Potential conflicts of interest
  5. References

I am a member of the Difficult Airway Society and contributed a small amount of advice prior to the publication of their guidelines.

I have been paid for lecturing by the LMA Company and Intavent Orthofix, manufacturers of laryngeal mask airways.

My department has received free and reduced price equipment from a number of airway manufacturers for use in research.


  1. Top of page
  2. The problem
  3. Solutions
  4. Potential conflicts of interest
  5. References
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