Airway skills are core to anaesthetic practice, yet training in them can be variable. This particularly applies to advanced skills such as fibreoptic intubation. Inadequate training in difficult airway management can lead to a lack of confidence or (perceived) competence when managing these situations as a consultant or specialist.
Instillation of local anaesthetic through a cannula cricothyrotomy can provide airway anaesthesia for an awake fibreoptic intubation; it also provides a valuable rehearsal of the skill required in the life-threatening ‘can't ventilate can't intubate' scenario.
We wished to establish how many awake fibreoptic intubations trainees believed they should perform to be competent and whether there was a training-gap between this target and their actual training. We wondered whether trainees had taken steps to circumvent this gap by attending courses or deciding for themselves that only specialist ‘airway anaesthetists' should perform awake fibreoptic intubations. Given its place as an emergency technique we also wanted to know if they had any experience of cannula cricothyrotomy. We were interested in the influence of ethical considerations on trainees' willingness to rehearse fibreoptic intubation on patients with apparently normal airways.
A questionnaire previously piloted in our own region was distributed to delegates attending the Annual Scientific Meeting of the Group of Anaesthetists in Training of the Association of Anaesthetists of Great Britain and Ireland (Oxford, June 2005).
The questions covered six areas:
- respondents' experience of fibreoptic intubation;
- the number of awake fibreoptic intubations respondents believed they needed to perform to become competent in the technique;
- number of cannula cricothyrotomies seen and performed;
- respondents' perception of fibreoptic intubation as a specialist skill;
- respondents' intentions regarding fibreoptic training courses (already attended, planned to attend or did not plan to attend);
- respondents' opinions regarding the ethical issues involved in performing a fibreoptic intubation purely for training in graded scenarios, from an asleep patient not specifically requiring endotracheal intubation to an awake patient who had fully consented to participate in a training procedure.
Questionnaires were handed to delegates personally, and respondents were invited to participate in a prize draw. This was to enhance response rate and reduce accidental duplication as entrants were checked against the delegate list.
Respondents who were staff grades, registrars employed in fixed-term training appointments or lecturers were grouped in the specialist registrar or senior house officer grade according to the number of years of experience in the UK. The Association of Anaesthetists provided the total number of delegates.
To maximize data utilization, where a numerical response was required but a non-numerical response was given, we included responses that could be assumed to be zero. No numerical substitution was considered for positive but unquantified answers. Respondents providing all numerical answers in the number of fibreoptic intubations performed section were also analysed separately. As the ethical scenarios were graded, only responses from those completing all five questions were analysed.
Data were collated using Microsoft® Access and Excel. Statistical analysis was performed using GraphPad Prism Version 4.03 (GraphPad, San Diego, USA). Numerical data were inspected for normality and then the D'Agostino-Pearson normality test (omnibus K2) applied. Non-parametric data were analysed with the Kruskal–Wallis test (using Dunn's post-test for intergroup comparisons) and the U-test. When comparing the number of asleep vs. awake intubations (all numerical data group), we used the Wilcoxon signed rank sum test (non-parametric matched pair analysis). This test was also used when considering the number of cricothyrotomies seen and performed (hypothetical value of zero).
Two hundred and twenty-one questionnaires were returned, i.e. a response rate of 76% (221/289). We excluded one illegible questionnaire and two from overseas delegates. The remaining (at least partially completed) 218 questionnaires were analysed. Inspection of the data revealed that most responses to the numerical questions were not normally distributed. Non-parametric tests were then used throughout to facilitate comparison.
Respondents (n = 199) were from 23 Schools of Anaesthesia, and the median number from each school was 6, (interquartile range (IQR) 3–13, range 1–26).
Table 1 shows responses by grade (of respondent) to the questions concerning competence and experience of procedures observed and performed. All groups of trainees believed that competence was achievable with 10 awake fibreoptic intubations, whereas the maximum median number performed was 4. Respondents believed that all trainees should be competent by the end of their training and that fibreoptic intubation skills were not specialist skills. The number of cannula cricothyrotomies seen and performed by the respondents was small but greater than zero.
Table 2 details the responses of those who provided numerical answers to all the ‘number of fibreoptic intubation' questions, including competence. Although the number of awake fibreoptic intubations performed in comparison with the number required for competence was not significantly different for trainees in their final year, 60% (12/20) still failed to achieve their own definition of competence.
The median number of awake fibreoptic intubations ‘to bestow competence' was higher (15, IQR 10.0–22.5) in the group who had performed 10 or more (14/120) awake intubations than in the group who had performed less than 10 (106/120, median 10, IQR 10–20), but this was not significant (P > 0.05).
The median number of (total) asleep fibreoptic intubations performed in the numerically complete group was 6 (IQR 2.0–16.5), this was significantly higher than the median awake value in this group (2.0, IQR 0–4, P < 0.0001, Wilcoxon signed rank sum test). When the number of intubations performed awake or asleep was considered according to the grade of respondent, there was a significant difference between the medians of the whole group (P < 0.0001, Kruskal–Wallis test), but only the medians for awake and asleep in the specialist registrar years 1 and 2 group (2.0 (IQR 0–2.0) and 6.0 (IQR 3.0–16.0)) and the specialist registrar years 3 and 4 group (3.0 (IQR 1.5–7.0) and 10.5 (IQR 5.0–19.0)) were significant (P < 0.001 and P < 0.01, respectively, Dunn's post-test). Respondents (Table 2) witnessed a median of 6.0 fibreoptic intubations (IQR 3.0–10.0).
Sixty seven respondents (n = 215, 31.2%) had already attended a fibreoptic training course, while 134 (62.3%) intended to do so; only 14 respondents (6.5%) did not intend to attend a course. There was no difference between these three groups in the number of awake fibreoptic intubations felt to bestow competence (P = 0.5745, Kruskal–Wallis test).
Nine of thirteen respondents (69.2% (n = 212 answering both the course and competence questions)) who thought that it was unnecessary for specialist registrars to be competent still planned to attend or had already been on a fibreoptic intubation training course. Only two respondents who did not intend to attend a course felt that all trainees did not need to be competent by the end of training and believed ‘fibreoptic airway skills are specialist'.
Two hundred and eight delegates answered all five ethical scenarios. The majority (82.7%) felt it acceptable to fibreoptically intubate an asleep patient without specific consent if they needed an endotracheal tube; however, the number who believed asleep fibreoptic intubation to be ethical fell to 22.1% when the patient could otherwise have been managed without tracheal intubation.
Only 10.1% of the respondents felt that it was ethical to perform an awake fibreoptic intubation on a patient with no anticipated airway problems without consent or explanation. This number rose to 78.4% if the procedure had been explained fully but consent was not sought. Even when consent had been sought to perform an awake fibreoptic intubation as a training procedure, which the patient could decline to participate in if he/she wished, 10.1% of the 208 respondents still felt it was unethical to do so.
Airway management has always been a cornerstone of anaesthetic practice . The American Society of Anaesthesiologists (ASA) guidelines  recommend the consideration of awake fibreoptic intubation in difficult airway management. The Royal College of Anaesthetists expect senior trainees (having completed at least 4 yr) to develop their practical skills in fibreoptic intubation. Their guidelines do not suggest an optimal number for training, although we agree with Popat  that numbers alone do not make an individual competent. The issue is not new; twenty-five years ago, Vaughan  commented, ‘…it must be essential that anaesthetists become competent in the use of fibreoptic instruments and that training is provided'. Ovassapian and Yelich  and Johnson and Roberts  suggested that acceptable expertise may be achievable after 10 fibreoptic intubations on asleep patients and 15–20 on awake patients. Smith and colleagues  suggested that rapid fibreoptic intubation was achievable with 18 training endoscopies.
Previously, Ovassapian and colleagues  reported that a 99% success rate with fibreoptic intubation could be achieved with a 6.5 h teaching programme. This required 4.5 h instructor teaching per trainee. A survey of New Zealand anaesthetists  (90 trainees, 296 consultants) reported that those who had performed 100 fibreoptic intubations regarded themselves as expert; those who had performed around 20 regarded themselves as competent, 15 as adequate and 4 as novice (medians, extrapolated from figure). These trainees performed median 4 fibreoptic intubations per year while the total number performed by a trainee was 8 (95% confidence interval (CI) 5–11).
Trainees returning our survey felt that competence was achievable with 10 endoscopies (all respondents group). This discrepancy may have arisen because the majority (including even final year trainees) had not performed the number of endoscopies they believed bestowed competence. Our finding that more experienced endoscopists had a higher numerical definition of competence might support this, but this was not statistically significant.
Our survey examined trainees' experiences of cannula cricothyrotomy. Instillation of local anaesthetic through the cricothyroid membrane can be part of airway anaesthesia for an awake technique. However, if few fibreoptic intubations are performed, training opportunities will be missed. Cannula cricothyrotomy is another difficult airway skill where a training-gap may exist. The incidence of ‘Can't ventilate can't intubate' is rare; however, guidelines  highlight the role of cricothyrotomy in an emergency, although exactly when it should be performed has been debated .
Hung  reported that 86% of Canadian programmes teach cricothyrotomy, although in a study conducted the following year  only 10% had previous experience of cricothyrotomy in patients. Skills can be taught on commercial mannequins or homemade models , although neither can truly represent clinical practice.
Wong and colleagues  suggested five cannula cricothyrotomies on models as the minimum training requirement, but how this extrapolates to clinical practice is unclear.
Preventable airway deaths  and failure to intubate the trachea  featured in both the ASA closed claims analysis  and the UK confidential enquiry into perioperative deaths . It is therefore unsurprising that fibreoptic techniques are in the national guidelines [2,10]. Dawson and colleagues  reported that 99% of trainees believed fibreoptic intubation to be a core skill. In our survey, a high number believed that all trainees should be competent by the end of their training.
The number who planned to attend (or had attended) a course is similar to other UK studies , although higher than in other countries . This has resource implications in the provision of time and trainers, although the benefits of structured training are known [8,18].
Ethical issues in fibreoptic intubation training are not new. Vaughan  recognized that some anaesthetists found the concept of practising awake fibreoptic intubation ‘unethical'. Studies around this time discuss training on anaesthetized patients [19,20], although Ovassapian and colleagues' scheme using sedated patients with topical airway anaesthesia was published in 1983 .
The Difficult Airway Society working party (reported by Popat ) suggested that ‘specific consent is not required for an advanced (airway) technique if the anaesthetist uses it regularly…'. This is supported by Bray and Yentis  who showed that patients felt consent was required for non-routine airway techniques, whereas anaesthetists felt this to be unnecessary. Unlike our survey, 64.4% (105/163) of their respondents were consultants attending a Difficult Airway Society (UK) meeting and the questions did not specify awake or asleep procedures. The New Zealand study  reported that 78% of trainees thought it appropriate to train on patients with normal airways, but only 29% thought that consent was required when training; again, awake or asleep was not specified.
We found that UK trainees believed informed consent was necessary when performing an awake fibreoptic technique for training. However, trainees perform significantly more asleep intubations than awake ones, and most did not believe that consent was required for asleep procedures. The role of asleep fibreoptic intubation is well described ; however, we believe that awake intubation is a different skill, with adequate airway anaesthesia fundamental to its success. Erb and colleagues' study  showed that it was possible for trainees to learn fibreoptic intubations on anaesthetized spontaneously breathing patients, perhaps better reflecting the awake scenario. Intubations on these asleep patients took longer, possibly demonstrating increased complexity. This may provide one ethical method of some appropriate training.
Training opportunities are influenced by trainers' opinions. Allen  found that 57% of consultants would avoid an awake fibreoptic intubation when a patient was awoken because of failure to intubate; 76% of this group felt awake fibreoptic intubation was unpleasant for the patient.
Bokhari and colleagues  found that 17/77 consultants in the same region would choose a blind (rather than fibreoptic) technique when faced with an unanticipated difficult airway as they lacked the training and experience. If senior anaesthetists are not confident in their own competence, then learning opportunities for trainees will be limited.
Difficulties in learning airway skills are not unique to British trainees. An American survey  showed that although 75% of 452 respondents favoured fibreoptic intubation in a patient requiring a caesarean section with an anticipated difficult airway (regional contraindicated), only 59% felt skilled in the technique. A German survey  found that trainees did not perform fibreoptic intubations regularly. Only 20% of New Zealand's registrars thought that there was adequate opportunity to learn fibreoptic intubation . This contrasts with Swiss studies [27,28] reporting a fibreoptic intubation rate of 8 and 13.5% (90% awake, 46% for training ), with a transtracheal catheter insertion rate of 1.9% .
Our survey's major flaw was the respondents who did not answer questions on the number of fibreoptic intubations numerically. This flaw was not apparent in our trial questionnaire (48 consultants and trainees). Even the collected data cannot be validated and our results may not reflect the opinions of all trainees.
We hope to investigate how the training course attended (lectures, model practice, participant nasendoscopy) affects the ongoing training need, and assess for how long mannequin-derived skills are retained. We intend to collate patient's experiences of awake fibreoptic intubation (difficult airway or training scenario) to correctly inform patients and anaesthetists what to expect.
The training-gap in the advanced airway skills we describe is not new [4,29]; nor, perhaps, are its solutions. McFetrich  concluded that although robust data showing clinical or knowledge advantage was lacking, the greatest use of simulators was for skills not readily taught on patients because of complexity and rarity. Simulation could address the ethical concerns of practising on patients. Martin and colleagues  found that trainees who practised on a complex mannequin demonstrated significantly better clinical endoscopy skills than those trained on a simple model. Naik and colleagues  showed that anaesthetists at the outset of their career could translate skills learnt on a simple model into more successful asleep fibreoptic intubations than their untrained peers. Ovassapian and colleagues  showed that a graduated training programme made trainees initially more successful in fibreoptic nasotracheal intubation.
Two studies [33,34] report awake fibreoptic intubation as not unpleasant when using course delegates as subjects. Ovassapian's study  with awake sedated patients found that only 1.6% would prefer not to undergo the procedure again.
These findings, and our similar experiences, have encouraged us to gain consent from patients with normal airways for awake fibreoptic intubation training. It is in this willing and consented group where the opportunity to practise cannula cricothyrotomy also exists.
In conclusion, trainees in the UK and Ireland have a training-gap in their advanced airway skills, as demonstrated by their experience of fibreoptic intubation and the technique of cricothyrotomy. This is despite their belief that fibreoptic intubation is a core skill. Their desire to learn obliges anaesthetists to provide appropriate structured simulation training to optimize clinical training opportunities. Anaesthetists will also have to compare their feelings about patients' perceptions of awake fibreoptic intubation to those in the literature.
The authors gratefully acknowledge the cooperation of the President, Council, GAT Committee and Secretariat (especially Jo Barnes) of the AAGBI without whose help this study would not have been possible. Funding for materials was provided by the Trainees' Fund, St Bartholomew's Hospital.
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