Time for a breath of fresh air: Rethinking training in airway management

We believe that the way in which we conceptualise ‘airway education’ needs to change. The last two decades of anaesthetic practice have seen a proliferation of airway devices and techniques, yet training and maintaining skills in airway management have not necessarily kept pace. The traditional model for learning continues to be based on apprenticeship, and this is subject to immense variability based on the skills and interest of the supervising anaesthetist, as well as case-mix and time pressure in the operating theatre [1]. Superimposed on this is the inadvertent consequence of safer working hours thus limiting the number of cases to which trainees are exposed. The ubiquitous use of the supraglottic airway has also reduced opportunities to practice many core skills such as face mask ventilation and laryngoscopy [1, 2]. The consequence of all this is the potential for large gaps in skill sets. Most airway education commentators now accept that clinical skills for airway management cannot be taught solely on patients [3–5]. Simulation training in airway management is recommended (but not mandated) by the Royal College of Anaesthetists (RCoA) [6] and in the Difficult Airway Society (DAS) guidelines [7]. The recent survey by Lindkær Jensen et al. in this issue of Anaesthesia [8] demonstrates that nearly a fifth of UK NHS hospitals still provide no formal, out-of-theatre training in airway management. Furthermore, the education that is provided is limited to trainees in many instances, such that fewer than half of NHS consultants themselves have access to in-house continuing education in airway management. Logically, if in-theatre teaching of airway skills is highly variable and out-of-theatre airway workshops are not universally accessible, expertise cannot be guaranteed in all newly qualified consultants nor maintained in experienced practitioners. This situation is not new, and similar calls to arms have been repeated since the mid 1990s [2, 9, 10]. With the recent release of the DAS 2015 guidelines for unexpected difficult or failed intubation and the subsequent commentaries [7, 11], this survey comes at an opportune time for the anaesthetic community to again reflect on how airway training is conducted. In this editorial, we will challenge the assumption that all anaesthetists need to possess the full range of technical skills for airway management. We will discuss what should constitute core skills and how these might be obtained and maintained using both clinical and workshop forums. Finally, we will explore which other members of the wider ‘anaesthesia team’ should be trained to help ensure patient safety.