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Summary

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

In airway management, poor judgment, education and training are leading causes of patient morbidity and mortality. The traditional model of medical education, which relies on experiential learning in the clinical environment, is inconsistent and often inadequate. Curriculum change is underway in many medical organisations in an effort to correct these problems, and airway management is likely to be explicitly addressed as a clinical fundamental within any new anaesthetic curriculum. Competency-based medical education with regular assessment of clinical ability is likely to be introduced for all anaesthetists engaged in airway management. Essential clinical competencies need to be defined and improvements in training techniques can be expected based on medical education research. Practitioners need to understand their equipment and diversify their airway skills to cope with a variety of clinical presentations. Expertise stems from deliberate practice and a desire constantly to improve performance with a career-long commitment to education.

Inadequate skill and poor judgement in airway management continues to lead to avoidable brain damage and death in occasional patients [1]. The expert panel that reviewed 184 cases of major airway complications in the Fourth National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society [1], concluded that poor judgement (59%) and education/training (49%) were the second and third most frequent causal and contributory factors (after patient factors; 77%). Difficult or delayed intubation, failed intubation and ‘cannot intubate, cannot ventilate’ situations accounted for 39% of events during anaesthesia. Deficiencies in airway assessment, under-utilisation of awake intubation, inappropriate use of supraglottic airway devices (SADs) and evidence of poor airway management planning were also noted. In a review of litigation related to anaesthesia in National Health Service (NHS) hospitals in the UK from 1995 to 2007, airway and respiratory related events accounted for 12% of all anaesthesia claims, 53% of deaths and 27% of cost, and were involved in 10 out of the 50 most expensive claims [2].

These studies contain important messages, that should help direct training in airway management towards improved patient care. Our aim in this review is to assess current training practice and discuss proposals to improve education in airway management in the future.

Traditional approach to learning airway management

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

“We now accept the fact that learning is a lifelong process of keeping abreast with change. And the most pressing task is to teach people how to learn.” Peter F. Drucker [3]

The traditional apprenticeship model of medical education, based on experiential learning in the clinical environment, is over 100 years old [4]. The operating room (OR) environment can provide opportunities for safe and deliberate practice of airway technique in patients with varied anatomy, pathology and physi-ology [5]. This has been, and remains, the most common form of training in airway management skills in anaesthesia. Apprenticeship training, however, is ad hoc, with varying and unpredictable exposure to appropriate cases, and consequent safety and ethical issues. Furthermore, opportunities to learn advanced airway skills are diminishing through increased use of the laryngeal mask airway, regional techniques, reduced training hours and pressures on clinical placements [6–8]. Care for the patient can be compromised during OR training. The workload of the instructing anaesthetist is increased during teaching, and vigilance may decrease [9]. Some exercises devised for OR airway training can, in fact, increase risk and may be considered unethical. These include choosing to place a tracheal tube, when an SAD would otherwise have been selected, to increase learning opportunities; or deliberately limiting the laryngoscopic view to practise more difficult intubations [10–13]. Potential for patient harm during this early part of the learning curve, and the question of whether consent from patients is needed, raise important practical and ethical issues [14]. Intubation via direct laryngoscopy, for example, is a complex technical skill [15]: its success rate is only 50% in novices [16] and a rate of 90% cannot be expected until 50 attempts have been made. Moreover, 18% of trainees still require assistance after 80 attempts [17]. The limitations outlined above affect the time it takes for trainees to achieve an acceptable level of safe, unsupervised practice.

The challenges associated with developing and maintaining airway skills are not restricted to trainees. Many senior anaesthetists will have honed their airway skills on the job, through trial and error. Many are self-taught and have adopted flexible bronchoscopy and the use of SADs or rigid indirect intubation devices without any formal instruction [18]. As senior practitioners, they are assumed to be experts on the basis of their many years of practice. In reality, the quality of technical care tends to deteriorate over years unless regular deliberate practice is maintained [19]. In one study, younger anaesthesiologists outperformed their older colleagues on all categories of measurement when performing cricothyroidotomy [20]. Knowledge and skills decay over time, but this decay can be arrested by practice [21, 22]. In a national survey of 386 anaesthetists, the average number of fibreoptic intubations performed per year was three for consultants and four for registrars. A paucity of appropriate clinical cases and, therefore, of opportunities for practice was considered the primary barrier to skill development [18].

Anaesthetists need to be skilled in a variety of techniques to manage a range of clinical presentations [23], but there is a tendency to limit skills to a few core techniques. Several surveys reveal a limited use of intubation techniques other than direct laryngoscopy, and inexperience with awake fibreoptic intubation and cricothyroidotomy [24–26]. It is encouraging that the number of techniques and devices available for managing difficult airways has increased dramatically over the last three decades, but this has also made it more difficult to acquire and maintain the broad range of airway skills that might reasonably be expected of an anaesthetist today. Inadequate knowledge contributes to the problem: for example, the ability to identify the cricothyroid membrane [27] or properly understand the Cormack Lehane classification [28].

While standardisation of equipment is associated with improved performance and patient outcomes [29], it is infrequently done. New airway devices are often adopted without formal teaching and without practitioners, reading instructions [30]. Practitioners teach themselves, without applying best practice [18]. This can lead to poor techniques and harm to patients [31, 32]. Educators need to improve training in airway management while practitioners’ skills need to be diversified to an adequate level of expertise without harming patients.

Developing expertise in airway management

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

Anaesthetists claim to be airway experts, but is this justified? Ericsson argues that while experience is part of being an expert, experience alone does not guarantee expertise. Ericsson has identified consistent behaviours that shape expertise and superior performance in non-medical domains such as sport and music [33]. Deliberate practice, immediate feedback, problem-solving and evaluation with the chance to repeat performance and modify behaviour are essential ingredients in the attainment of expert performance [34]. These concepts apply equally to the development of airway skills. The learning curve for most airway devices is biphasic: reasonable competence can be achieved within 30 cases, but performance continues to improve even after 100 cases [35]. It is during this early phase of learning that individuals pass through the cognitive and associative phases where development is enhanced by teachers, trial-and-error and problem-solving. Eventually, performance plateaus, procedures become effortless and a state of automaticity is reached. Ericsson cautions that this automaticity can lead to arrested development rather than continuing enhancement of expertise. The danger is that, once a behaviour has become automatic, it is difficult to modify: Ericsson cites the tying of shoelaces as one such automated behaviour. If direct laryngoscopy becomes automated, it may be difficult to modify one’s technique to cope with a rare or unexpected situation. A patient with a difficult airway demands an anaesthetist who has the expertise to modify his or her technique as necessary. The risk is that, without deliberate practice, many practitioners will not advance beyond the stage of automaticity, and will perform at a mediocre level for the rest of their careers (Fig. 1). Advanced expertise requires increased control over performance. Experts counter arrested development by deliberately and regularly seeking challenges outside their comfort zone as opportunities for deliberate practice. Such practice should be distributed at regular intervals over a prolonged period of time [37]. Deliberate practice may be integrated into clinical practice, but it can perhaps be more readily obtained in skills laboratories, which provide the opportunity to accelerate learning through simulation. For anaesthetists to retain the mantle of airway experts, they need to be constantly striving to improve performance.

image

Figure 1.  Illustration of the qualitative difference between the course of improvement of expert performance and of everyday activities. The goal for everyday activities is to reach as rapidly as possible a satisfactory level that is stable and ‘autonomous’. After individuals pass through the ‘cognitive’ and ‘associative’ phases, they can generate their performances virtually automatically with a minimal amount of effort (see the grey/white plateau at the bottom of the graph). In contrast, expert performers counteract automaticity by developing increasingly complex mental representations to attain higher levels of control of their performance and will therefore remain within the cognitive and associative phases. Some experts will, at some point in their career, give up their commitment to seeking excellence and thus terminate regular engagement in deliberate practice to further improve performance, which results in premature automation of their performance (adapted from Ericsson [36]). With kind permission from Professor K. A. Ericsson, and the publishers.

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Defining the airway curriculum

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

Many organisations involved in training doctors in general, and anaesthetists in particular, have been engaged in reviewing their curricula over recent years. Notably, the Australian and New Zealand College of Anaesthetists (ANZCA) is currently undertaking a comprehensive curriculum review (ANZCA Curriculum Redesign Project) [38]. A key feature of the revised curriculum of this College is likely to be the identification of clinical fundamentals for anaesthetists, of which airway management is one. The intent is to ensure that anaesthetists achieve and formally demonstrate appropriate levels of competence in a defined set of learning outcomes within these clinical fundamentals at each stage of their training before advancing to the next stage. Airway management will be explicitly addressed within the curriculum, and expected competencies at different stages of training will be defined (Table 1), with a series of assessments to ensure that these are attained. Initiatives are also being considered by ANZCA to ensure that these essential competencies in airway management are not only acquired in training but also maintained after graduation as a specialist. Comparable developments have occurred within the Royal College of Anaesthetists.

Table 1.   An example of a minimum skill set to be acquired by a trainee during an airway rotation.
• Optimal bag-mask ventilation technique
• Optimal direct laryngoscopy and intubation with a range of laryngoscopes and intubation aids
• The use of supraglottic airways
• The use of rigid optical devices including videolaryngoscopes and optical stylets
• The use of flexible bronchoscopes
• Cricothyroidotomy

A staged approach to developing airway expertise

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

With the advent of airway management as a clinical fundamental within the curriculum, more airway training programmes will be required. Formal programmes in airway management have already been in existence for many years. The number of airway residency programmes in the USA and Canada has increased over the last 16 years, and their content and modes of teaching have evolved [39]. A graduated system of training that reinforces and expands participants’ existing knowledge and skills is ideal. Course content should follow a syllabus reflecting guidelines and best practice (Table 2). Numerous airway guidelines have been published internationally with varying emphasis and content, and these have been recently reviewed [40, 41]. It is important that guidelines are regularly updated, are based on good evidence and are developed in accordance with methodological standards [42], especially if these guidelines are to be used to evaluate a doctor’s practice [43]. Courses should include background reading material (which can be provided electronically) to support course content and provide core information. Airway training programmes often depend on institutional support and funding. It is helpful for institutions to appoint coordinators to act as champions for these programmes [44, 45].

Table 2.   Items that might be included in an airway management programme.
• Airway anatomy and physiology
• Assessment of the airway
• Maintenance of oxygenation and ventilation
• Avoidance of trauma during airway management
• Utilisation of pre-planned strategies
• Importance of calling for help and when to do this
• Airway algorithms
• Management of known and unexpected difficult airways
• Establishment and confirmation of an open airway
• Awake intubation
• Rapid sequence induction
• Intubation via a supraglottic airway
• Retrograde intubation
• Emergency techniques for cannot-ventilate cannot-oxygenate situations
• Extubation strategies
• Dissemination of information concerning the critical airway
• Human factor training in relation to airway management

A best practice approach should be adopted when teaching skills [46, 47]. Techniques and equipment to be included in the training programme should comply with guidelines [48] and be reflected in the practices and equipment held in local hospitals. Teaching should take into account the level of expertise of the learner. In an ideal setting, novices should start their training on part-task trainers in an airway training room, then progress through more sophisticated modalities, perhaps using cadavers or anaesthetised animals, or animal tissue preparations [49–53]. They should then progress to clinical training under supervision once they have achieved competence using simulation. Each of these approaches has advantages and disadvantages including cost, the requirement for ethics committee approval and potential morbidity. Awake fibreoptic intubation can be practised on volunteers [54], but we have reservations about subjecting trainees to procedures with a risk of morbidity, even with their permission [55]. A comprehensive review of teaching techniques has been provided by Stringer et al. [56].

Understanding the function and limitations of airway equipment is fundamental to safe airway management. The tendency to pick up new devices and work out how to use them from first principles can lead to patient harm. Coroners’ cases have been reported where anaesthetists were unable to assemble emergency equipment [57]. Use of improvised emergency equipment can lead to delays in patient care or poor outcomes [58, 59]. Guidelines have been published that emphasise standardisation of equipment, whilst still providing a range of alternative devices to cope with unusual circumstances, and quality control measures to promote a culture of safety [48]. Suggestions have been made to ‘sign off’ practitioners to use new equipment only after they have demonstrated competence in its use [60]. Parallels can be found in other clinical areas – for example, approval to perform percutaneous carotid artery stenting is now dependent on relevant simulation-based training by physicians [61].

Video can enhance training and, in particular, can help demystify direct laryngoscopy [62] and fibreoptic intubation [63]. One example of this is the Airway Cam™ Direct Laryngoscopy Video System (Airway Cam Technologies, Inc, Wayne, PA, USA), which consists of a head-mounted camera designed to display the laryngoscopist’s view on a screen for trainees or supervisors to see [64]. Airway Cam [58, 59] images have been recorded for training DVDs and for hands-on instruction [16, 62]. Video can also facilitate assessment with global rating scores [65]. A number of studies describe the benefit of imaging the larynx with videolaryngoscopes to assist instruction during training in laryngoscopy [66–69].

Advancement of airway skills beyond the proficiency needed for routine anaesthetic practice requires opportunities for dealing with patients whose airways are more challenging. Airway fellowships provide such opportunities and also allow senior trainees to engage in relevant research, teaching and the development of advanced clinical skills. Graduates from such fellowships serve as a resource to promote and provide education in airway management [44]. Airway workshops have been in existence for decades [70] and vary in content. They are usually run by enthusiasts and often focus on techniques such as flexible bronchoscopy, cricothyroidotomy or direct laryngoscopy [16, 52, 54]. Participants at such workshops report improvements in accuracy and confidence with airway evaluation, adoption of previously unfamiliar airway devices and changes in practice related to managing patients with difficult airways [71]. However, unless the learner follows the workshop with ongoing deliberate practice, the benefits may be short-lived; providing airway laboratories in the workplace may be an effective way of facilitating this. There is considerable interest in taking simulation to the clinical environment [72].

The potential for simulation to enhance learning

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

Simulation provides a way of teaching and evaluating technical and cognitive skills (including skills related to human factors) outside the OR, without risk to patients and away from the pressures of clinical work.

The range of simulators for use in anaesthesia is wide [73]. As indicated above, certain basic skills can be acquired using very simple simulators [74], whereas more sophisticated simulators offer opportunities to achieve advanced educational objectives [75]. Although part-task trainers can be useful to teach airway techniques such as SAD insertion, direct laryngoscopy and other procedures described in airway algorithms [76, 77], educators should be careful when choosing models and manikins, to ensure that they have adequate fidelity and are fit for purpose. Some manikins have been criticised as unrealistic with poor laryngeal anatomy, rigid structures and inability to simulate reversible airway obstruction [77, 78]. There is unequal performance for different types of manikins using various SADs [79]. Training conditions provided by manikins are not necessarily the same as in patients, and the use of some SADs by novices is more difficult in patients than manikins [80]. Careful analysis of training needs should be applied before acquiring appropriate simulators. To teach each step of the Difficult Airway Society guidelines effectively, for example, more than one type of airway training model is required [77, 81]. An advantage of using a variety of manikins is the finding that trainees tend to adapt their skill to a particular manikin, and therefore providing them with variety of manikins can lead to a broader range of skills [82].

Simulation can compensate for inadequate clinical experience by providing the opportunity to perform multiple repetitions of a procedure over a short period of time. In a study using the Accutouch® flexible bronchoscopy simulator (CAE, Montreal, Quebec, Canada), novice residents performed an average of 17 oral fibreoptic intubations in 39 min, and demonstrated significant improvement in clinical dexterity with the flexible bronchoscope after this relatively brief period of training [83]. Simulators allow trainees to advance at their own rate and training can be tailored to specific tasks and procedures [17, 84]. Simulation may have a role in identifying deficiencies in practitioners and contributing to their retraining [85].

In general, simulation in anaesthesia has high face validity and participants tend to enjoy simulation-based education, but improvement in patient outcome consequent to its use in training is not well established. Simulation is usually expensive, and its cost-effectiveness in relation to alternative educational methods has not been well established, although the advantages outlined above may lead to financial savings: for example, training using simulators can reduce repair costs for fibreoptic equipment by up to 84% [86]. Standards in relation to simulators and simulation facilities have been slow in coming [87].

Human factors, systems and team: impact on airway management

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

Sound knowledge and skills are not enough to ensure safe management of the airway. Training in human factors is also important. Human error is implicated in as many as 80% of anaesthetic incidents [88]. In the Australian Incident Monitoring System study, data from anonymous incident reporting were analysed and categorised. Human failures that included error of judgment, failure to check, fault of technique, other equipment problems, inattention, haste, inexperience and communication problems were found in 83% of reports [89]. Poor communication and teamwork were amongst the factors contributing to airway misadventures in the NAP4 study [1]. Effective teamwork is important in airway management, and so is the ability to make appropriate decisions in good time; there is evidence that even experienced practitioners may feel considerable reluctance to progress to a surgical airway in an emergency, and more work is needed to find effective ways to address this reluctance [90, 91].

In recognition of the importance of human factors in the management of anaesthetic crises, the ANZCA commissioned the development of a course, the Effective Management of Anaesthetic Crises (EMAC). This two-and-a-half-day, simulation-based course includes a strong theme of human factors and teamwork training. A half-day of this course is dedicated to management of airway crises, and includes skills stations, airway drills, and instruction on human error and decision-making. This is reinforced in immersion simulations of critical events, using a whole-body computerised manikin, followed by debriefing and facilitated reflective learning [92]. The aim is to ensure that anaesthetists are ready, willing and able to intervene effectively in airway crises, and in fact, to recognise potential problems and thereby avoid adverse events. While EMAC is now a compulsory component of training and recognised for continuing professional development, consideration could be given to regular, compulsory training for anaesthetists in airway management similar to the requirements of aviation pilots.

One of the key steps in managing a difficult airway is to call for help. Trained anaesthetic assistants have been shown to improve safe management of simulated anaesthesia crises [93] and their help may be particularly useful, provided they understand their role in the management of difficult airways. Anaesthetists and their assistants need to be familiar with their environment and particularly with the required equipment and its whereabouts in their own institution. It is therefore worrying that an audit of airway management equipment in a metropolitan region in New Zealand found that 20% of anaesthetic and non-medical staff had never been orientated to the difficult airway container and did not know the contents [94]. It is likely that such deficiencies exist in many other countries.

It is useful to consider techniques used by the airline and other industry to mitigate the risk of human error. Standard operating procedures and checklists are an integral part of safe practice in many high reliability organisations, internationally [95]. Relevant checklists for anaesthesia and surgery include the ‘Crisis Management Manual’ from the Australian Patient Safety Foundation [96], a new crisis checklist from Gawande’s group at the Harvard School of Public Health [97] and the World Health Organization’s Safe Surgery Checklist, which includes an airway component [98]. The Fourth National Audit Project also recommended use of checklists and standard operating procedures for a number of circumstances such as intubation outside the operating theatre and rescue of the accidentally dislodged airway in the intensive care unit [1].

Assessment of airway competence

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

An essential element of any airway curriculum is assessment. Practitioners have a personal, professional and ethical responsibility to maintain their own competence, and the discharge of this responsibility has traditionally emphasised self-regulation [99]. Unfortunately, doctors are not good at assessing their own performance [100]. They tend to overestimate their own ability, and this tendency is often strongest in those individuals with the lowest competence [101]. Some training programmes require trainees to record their experience in log books, but self-reported log books are unreliable and their validity as a tool for assessing competence has not been well established [102]. Direct observation of performance using validated assessment tools, incorporating checklists or rating scales, is more reliable [103], but more work is needed to validate approaches to the summative measurement of anaesthetists’ performance, including work on faculty development [104].

Periodic assessment and re-certification of competency, using validated workplace evaluation tools [105], are reasonable expectations in competency-based approaches to training and the maintenance of skills [43, 106]. Participation by anaesthetists in approved continuing professional development programmes is now required in many countries, but few of these programmes appear to mandate demonstration of competence in managing difficult airways. Mandatory competency-based difficult airway management training at the University of Pittsburgh is linked to practising privileges [107]. Whether demonstration of such skills will form a part of revalidation for anaesthetists in the UK is yet to be determined. However, simulation can be expected to have an increasingly important role in assessment in the near future. Hesitancy in adopting simulation in this way has been grounded in concerns that assessment of this type needs to be reliable, valid, feasible and cost-effective [103].

It is worth comparing the situation in anaesthesia with that in the airline industry. Commercial airline pilots are required to pass assessments integrated into their regular, competence-based training in flight simulators to retain their licence to fly. If they fail, they are taken off flying, but in the first instance, intensive remedial training usually follows with the aim of reinstating the licence as soon as possible. This is an important philosophical point – the aim is not to remove their ability to work; rather it is to ensure that they are competent to do so safely. This is therefore less draconian than at first it might appear, and provides a model that has much to offer in anaesthesia (and more broadly in medicine). It could be argued that simulation-based evaluation used in this way would add value in supplementing current methods of assessing competence.

Conclusions

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

Education in airway management is undergoing a much-needed change. The introduction of competency-based medical education and the explicit definition of airway management in the curriculum as a clinical fundamental should lead to greater formalisation of airway training programmes. We can anticipate improvements in training techniques as a result of research into medical education. Trainees can expect the assessment of their competence in airway management to become much more rigorous in the near future. Regular reassessment of this competence is likely to become the norm for both trainees and qualified practitioners.

These changes will affect all anaesthetists. A career-long commitment to relevant education and maintenance of skills is clearly integral to the credibility of anaesthetists’ claim to being experts in airway management.

Acknowledgements and Competing Interests

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References

We are grateful to Captain Robert Henderson, who is a psychologist and a senior Air New Zealand pilot and instructor, for his advice and knowledge during the preparation of this manuscript, and to Dr Margot Jerram who assisted in preparing the manuscript. The study was funded solely by institutional and departmental sources. PAB has received free airway equipment for research and teaching from a variety of manufacturers. He is also the owner of Airway Simulation Ltd. which has developed the Orsim™ bronchoscopy simulator. RHR receives royalties from Oxford University Press. AFM has a financial interest in Safer Sleep LLC. No other competing interests declared.

References

  1. Top of page
  2. Summary
  3. Traditional approach to learning airway management
  4. Developing expertise in airway management
  5. Defining the airway curriculum
  6. A staged approach to developing airway expertise
  7. The potential for simulation to enhance learning
  8. Human factors, systems and team: impact on airway management
  9. Assessment of airway competence
  10. Conclusions
  11. Acknowledgements and Competing Interests
  12. References