*Presented in part at the Difficult Airway Society Meeting, Dublin 5-6 October 2006

Introduction

Several editorials and review articles have voiced concerns about the availability of airway training in the United Kingdom (UK) ₁₂₃₄₅. Among other solutions, these authors have suggested the usefulness of Airway Training Workshops (ATWs) in order to maintain and improve airway skills amongst anaesthetists ₁₂₃₄. Workshops in general are there to offer an environment where participants have every opportunity to participate, learn, and produce. No national data is available about these ATWs. We conducted this national survey to determine the availability, setup and content of the ATWs in the United Kingdom (UK), and to enquire from respondents whether they feel guidance and regulation from the Royal College of Anaesthetists (RCA) and/or the Difficult Airway Society (DAS) are required.

Method

A structured questionnaire (appendix) was sent by post to the college tutors of all the 273 anaesthetic departments in the UK. Contact details of these were provided by the RCA. Our questionnaire was initially piloted to enhance its validity and reliability. For the purpose of the survey, an ATW was defined as “Airway training provided for Anaesthetists in a classroom-based (off-patient) environment”. We asked that questionnaires be completed by the consultant most involved in organising airway training in the department. Six weeks later, a reminder letter was sent to those departments that had failed to reply. No ethic committee approval was sought as patients were not included in our survey. Respondents were assured that confidentiality would be respected and that the data would be presented in a way that the source would not be identified. All data was collated on to a Microsoft Excel spreadsheet (Microsoft Corp, Seattle, WA, USA) and then subsequently analysed.

Results

Of the 273 questionnaires posted, 219 replies were received giving a response rate of 80%. There were 99 ATWs organised by 92 departments (42%). Data are presented for these 99 ATW. 74% of these were solely organised for the benefit of anaesthetists working locally in the department. The majority, 81%, lasted only one day or less. The frequency and the venue where the ATW is conducted are shown in tables 1 and 2 respectively.

Figure 1

Table 1: Frequency of ATW

Figure 2

Table 2: Site of the ATW (N=99)

Most workshops concentrated on teaching advanced airway skills (table 3).

Figure 3

Table 3: Airway skills taught in the ATW

21 (21%) were dedicated only to fibreoptic intubation (FOI) techniques. The training models used consisted of mannequins of differing types (79%), hole in box models (42%), simulators (29%), fellow participants (10%) and cadavers (8%). While 72% of the workshops were free of charge, commercial courses charged fees between £50 and £400. The workshops were advertised within the local department in 70%, the region in 23%, on the DAS website in 12% and in an anaesthetic journal in 8%.

59 respondents (64%) agreed or strongly agreed that guidance should be available from the DAS and/or RCA, while 25 (27%) were undecided. Only 24 (26%) respondents agreed or strongly agreed that regulation should be available from the DAS and/or RCA, while 38 (41%) were undecided.

Discussion

The programme of training leading to a Certificate of Completion Training (CCT) in anaesthesia, published by the RCA identifies airway management as an essential skill that has to be acquired during the different stages of anaesthetic training ₆. While there is no distinction between ‘basic’ and ‘advanced’ airway training, the syllabus suggests that senior trainees should be exposed to specialties which deal with difficult airway such as Maxillo-facial surgery, the management of burns and ENT surgery ₆. In the last few years, there have been many publications doubting the quality and availability of airway management training in the UK ₁₂₃₄₅. Many reasons have been cited for these deficiencies and are summarized as:

1. A reduction in training opportunities following the Calman report in 1993 ₇, the European Working Time Directive in 2004 ₈ and the increasing use of peripheral and regional anaesthesia ₁

2. A possible increase in the number of incidents related to poor management of the airway ₉

3. The airway management field has been flooded with new devices and techniques. While this is considered to be good news, this has generated confusion among anaesthetists in relation to what are considered fundamental airway skills ₁₀ and to which pieces of airway equipment have good evidence of performance.

Up until recently, most authors who raised their concerns about airway management tended to concentrate on the lack of opportunities for tracheal intubation ₁₂₃₄₅. Airway management has, however, been continuously evolving in the form of the introduction of new drugs, techniques, and devices _1112131415. Since the Laryngeal Mask Airway (LMA) was first used in 1988 ₁₆, many other supraglottic devices, such as the Proseal LMA, have been added into clinical practice. Although, Macintosh laryngoscopy remains the standard technique for endotracheal intubation, many techniques based on the concept of fibreoptic visualisation have surfaced in recent years. Devices such as the Intubating LMA, Airtraq®, LMA CTrach™ are gaining popularity and many are described in the American and British Difficult Airway algorithms ₁₇₁₈. Therefore, anesthetists arguably have an obligation to be well trained and to maintain their skills on these devices and techniques.

Among the many possible solutions, ATWs or classroom–based ‘off patient’ teaching, have been suggested in order to maintain and improve airway skills ₁₂₃₄. The ATWs provide an opportunity for delegates to learn and practice skills in an ‘off patient’ environment. Dexterity skills required to master some of the equipment can be learnt on models and mannequins before these are used on patients thus improving safety. One would want participants leaving the workshop feeling energised and eager to try out their new learning “on the job” ₁₉.

Learning by experience alone, without the benefit of structured training and education, is a slow and “hit and miss” process. Without the structure of workshop and formal training programmes, it is more difficult to ensure that experience alone is providing all the important training needed. Classroom teaching is a poor substitute to learning by experience, but, when combined with learning on the job, the learning process should be enhanced. ATWs do this by guiding the learning through a safe and controlled environment, and by providing immediate feedback to participants ₁₉.

In our survey, only 92 anaesthetic departments (42%) organised airway-training workshops on a regular basis. This number is probably insufficient to cover all practising anaesthetists. It is however encouraging that about three quarters of these are for training anaesthetists locally as recommended by Cook ₃. We also note shortfalls related to the organisation of these ATWs. There were significant differences in content, set up of skills taught, and the training models used in workstations. Most of them lasted less than a day. 21 ATW (21%) were dedicated only to fibreoptic intubation techniques. Simulators have been recently introduced in training junior and senior anaesthetists ₂₀. They offer valuable experience especially for rare emergencies like the unanticipated difficult airway intubation. They could be useful in regularly practising the DAS guidelines. In our survey, simulators were used in only 29 ATWs.

The diversity in ATW organisation raises some other concerns. In the new National Health Service, quality management has gone through an impressive development ₂₁. Total quality management (TQM) requires that organisations make themselves transparent, i.e. demonstrate that they are doing the right things and are doing them in the right way ₂₁₂₂. Currently, the RCA, the DAS and the Association of Anesthetists of Great Britain and Ireland do not offer any guidance or regulation of these workshops. We only found one workshop dedicated in training the trainers in relation to airway management _23242526. Our survey suggests that respondents would prefer guidance form these bodies. It is interesting that only a quarter of the respondents would agree to regulation of ATWs by these bodies. This discrepancy could be due to the way in which we asked the questions. On the other hand 28% of ATW were “commercial” and charged between £50 and £400. Given that the purse strings governing study leave budgets continue to tighten in most hospitals ₂₇, many trainees and consultants will choose not to seek further airway training, if none is available within their departments.

In summary, ATWs in the UK appear to be limited in number, diverse in content and setup, and lacking “standardised” national learning objectives. Recent changes in training structure and study leave budgeting seem likely to compromise the availability of airway training for UK anaesthetists. The data that specifically demonstrates that airway training in the UK is inadequate does not exist and, until it does, the case for improving the status quo remains rather weak. We do feel, however, that there is a case for UK Anaesthetic regulatory bodies such as the RCA or the DAS to examine ways of maintaining and improving airway skills training. One part of this must involve ATWs and perhaps there is a need to develop recommendations for the learning objectives of such workshops. The majority of ATW organisers in our survey (62%) want guidance from DAS and/or RCA.

Appendix: Questionnaire sent to College tutors

Unique Identifier No:

PLEASE TICK ALL APPROPRIATE ANSWERS. SOME QUESTIONS MAY HAVE MORE THAN ONE APPROPRIATE ANSWER.

1. Does your department or hospital organise an ATW

2. Where does the ATW take place?

3. How often does ATW take place?

4. What is the duration of ATW?

5. How many trainers teach on the ATW?

6. Where do the trainers come from?

7. How many delegates participate in each ATW

8. What is the proportion of “local” versus “visiting” delegates?

9. What is the grade of delegates?

10. What are the main techniques taught in the workshop?

11. What is the proportion of theory (lectures) versus practical (hands on)?

12. Which training models are used in workstation?

13. How much do you charge per delegate?

14. How do you advertise the workshop?

15. Do you think the Royal College of Anaesthetists and/or the Difficult Airway Society should have a role in offering?