We read with interest the recent article by Graeser et al.1 evaluating the validity of three types of bronchoscopic simulators for the attainment of flexible optical intubation skills.
We note that in the study, an early prototype of the ORSIM virtual reality bronchoscopy simulator (Airway Simulation Limited, Auckland, New Zealand) was used, with some software malfunction, and so data regarding participants’ evaluation of the realism of the simulators were omitted. In our centre, we have purchased the commercially available ORSIM (version 1), which we use both as a teaching adjunct in theatre and during formal training workshops. We recently conducted a survey at our advanced airway training course, to evaluate the participants’ opinion of ORSIM as a fibreoptic skills training tool.
Thirty-eight delegates spent up to 15-min training on ORSIM and then completed a questionnaire. The participants were all senior anaesthetic registrars in their fourth to seventh years of training. The range of scenarios available were normal anatomy, base of tongue lesion, retropharyngeal abscess, carcinoma of the larynx, epiglottitis, macroglossia and airway trauma. Twenty-nine of 38 (76%) performed up to three scenarios, and nine of 38 (24%) performed up to seven scenarios. They were asked to grade responses to a series of six questions on a five-point Likert scale (Fig. 1). The majority of respondents answered either strongly agree or agree to all questions. Trainees were also asked to give an overall score for ORSIM as an educational tool to learn fibreoptic handling skills. The mean score was 8.5 out of 10. With the results of the questionnaire and feedback from trainees, we feel that simulation is a valuable addition to our existing training methods and the advantages of ORSIM specifically are its portability, ease of use and its high definition graphics in a range of difficult airway scenarios.
The question of what defines competence for fibreoptic intubation is open to debate. Graeser et al.1 were attempting to evaluate the use of simulation to assess basic competence prior to training in actual patients, but were not able to establish validity. In a survey previously reported in this journal by McNarry et al.2 of 221 UK trainees, it was found that they perceived that competence for fibreoptic skills would be achievable with 10 intubations. The majority reported a training gap between their perception of the number needed for competence and their actual number of intubations achieved. Simulation will have a role in addressing some of the factors contributing to this gap. However, although scope handling may be improved, the limitation of simulation for awake fibreoptic intubation training will be the lack of haptic feedback, and lack of learning accessory techniques such as topicalisation of the airway, well tolerated sedation and tube advancement, all central to the success of the overall procedure.
In our centre, another means by which senior trainees gain fibreoptic experience is by attending outpatient surgical head and neck clinics, where they can perform 10 to 20 supervised flexible naso-endoscopies in awake patients. We have found that this experience not only greatly improves scope handling but also acts as a bridge between simulation training and awake fibreoptic intubation.
In general, when teaching and assessing fibreoptic skills, we believe a multifaceted approach should be taken; from the more didactic teaching of nasal, pharyngeal and laryngeal anatomy, to the use of manikins and virtual reality simulation for scope handling dexterity, through finally to supervised performance on patients. Rather than an arbitrary assessment of numbers performed in isolation, it is the frequency of performance of successful intubation that is more indicative of competence and skill retention.
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1. Graeser K, Konge L, Kristensen MS, et al. Airway management in a bronchoscopic simulator based setting. Eur J Anaesthesiol
2. McNarry AF, Dovell T, Dancey FML, Pead ME. Perception of training needs and opportunities in advanced airway skills: a survey of British and Irish trainees. Eur J Anaesthesiol