BJA Advance Access originally published online on July 27, 2006
British Journal of Anaesthesia 2006 97(4):473-475; doi:10.1093/bja/ael190
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A Scottish National Prospective Study of airway management skills in new-start SHOs
Western Infirmary, Glasgow UK
*Corresponding author: Department of Anaesthesia, Crosshouse Hospital, Kilmarnock KA2 0BE, UK. E-mail: cwhymark{at}doctors.org.uk
Accepted for publication June 6, 2006.
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Abstract |
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Background. There is increasing concern about the ability of junior anaesthetists to manage the airway correctly and alarm that this may lead to adverse events.
Methods. We monitored the airway management skills of new-start anaesthetists in Scotland for 3 months.
Results. Experience with the laryngeal mask airway was satisfactory but there was wide variation in numbers of facemask and tracheal intubation cases.
Conclusions. We recommend that facemask anaesthesia is given a high priority in the formative months and that a target number of intubations should be carried out before providing anaesthesia without direct supervision.
Keywords: airway, maintenance; intubation; training
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Introduction |
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Successful airway management requires competence in basic airway skills including bag and mask ventilation, tracheal intubation and use of the laryngeal mask airway (LMA®).
New-start anaesthetists must master these core skills before they commence on-call duties at 3 months. Previous work1 in the West of Scotland highlighted domination of practice by the LMA and raised concerns that this was at the expense of practical experience with both facemask only cases and intubation. We have investigated further to determine whether this is a widespread problem affecting all new-start Senior House Officer (SHO) anaesthetists. The aim of the study was to take a snapshot of airway management experience gained by a cohort of new-start SHOs in their first 3 months of anaesthesia and to discuss whether this experience was sufficient to expect competence in airway management skills appropriate to this stage of training. |
Methods |
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New-start SHOs in Scotland due to commence February 2004 were identified by contacting the Royal College of Anaesthetists Tutor of each anaesthetic department 2 months earlier. The College Tutors agreed to their trainees taking part in the study. On taking up their posts, these SHOs received an explanatory letter and an airway training booklet to complete during their first 3 months. This booklet was designed, compiled and distributed by the authors. It included two pages for each month. One page had separate areas to record the number of facemask and laryngeal mask cases using the five bar gate system. The second page comprised a grid to complete for each intubation carried out and to document the view at laryngoscopy using the Cormack and Lehane system. The booklets were purposefully made to be slim and lightweight and the trainees were instructed to carry the booklets with them in theatre and to record the data contemporaneously. They were asked to record the airway management technique used for each case as solely facemask (with or without an oro-pharyngeal airway), LMA or tracheal intubation. The trainees were contacted by telephone at the start of the study period to ensure that they had received the booklets and again at the end to request return of the booklets.
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Results |
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A total of 26 new-start SHOs were identified in 12 hospitals throughout Scotland. All were included in the study, and 19 sets of data (73%) were returned. All datasets had been completed correctly and were included in the analysis.
A total of 3723 cases were carried out by 19 trainees. The results show that most cases were carried out using the LMA (1698 cases, 46%). A total of 1167 patients had tracheal intubation (31%) and 858 cases were carried out using a facemask (23%).
The number of cases logged by each trainee varied widely. The average number of cases per trainee was 45 facemasks, 89 LMAs and 61 tracheal intubations. The median number of cases was 27 facemasks (interquartile range 13–70), 86 LMAs (interquartile range 70–104) and 56 tracheal intubations (interquartile range 47–68) (Table 1). Out of 19 trainees 9 carried out fewer cases than the median in facemask and tracheal intubation categories. One trainee did not do facemask cases at all.
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Discussion |
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Much has been written about training for dealing with difficult airways.2 This is laudable and helps to raise the profile of airway management as the fundamental anaesthetic skill-set but we believe that attention should be concentrated on correct management of the routine airway in early SHO training.
It is now apparent that the number of cases carried out by trainee anaesthetists is declining.3–5 Tomlinson4 comments that contemporary Specialist Registrars work 
73% of the hours worked by Senior Registrars in 1991. The pattern of work is also changing. Yarrow and colleagues5 found that the monthly number of tracheal intubations fell from 450 to 280 between April 1995 and December 2001 in a typical UK district general hospital.
The relationship between experience and competence is difficult to define. This study looked at experience only and did not attempt to measure the competence with which the airway was managed. There is concern, however, that decreasing experience is being translated into problems with poor airway management and, more importantly, adverse outcomes.6 7 Previously, the duration and intensity of anaesthetic training dictated that all anaesthetists became airway experts almost by default.8 This is no longer the case. The trend of falling case numbers will not be reversed and ensuring that trainees become competent is now of prime importance. We feel that trainees must master all three basic airway skills before providing anaesthesia without direct supervision and agree with Cooper6 that the emphasis on teaching details of good airway management has decreased. Departments must ensure that trainees make maximal use of the training opportunities available to them and are directed to appropriate lists as fits their needs.
Correct management of facemask anaesthesia is essential. It is of grave concern that one SHO in the study had no experience of this fundamental skill and a further 8 of 19 fell below the median value of 27 cases. It is more difficult to learn successful airway management with a facemask than with an LMA.9 While both skills are important during a failed intubation scenario, we feel that there should be much greater emphasis on facemask anaesthesia in the formative months. New-start SHOs should be directed to theatres where facemask anaesthesia is practiced, for example Day Surgery.
It has been suggested that LMA use should be limited in the first 3 months.10 The LMA is often the best airway option and is the cornerstone of current anaesthetic practice. This was reflected in our study, accounting for 46% of cases. Also, correct LMA use can be life-saving in a patient who is difficult to ventilate with a facemask or to intubate. LMA insertion is an easy skill to learn and retain.11 Anaesthetists must be competent to manage LMA cases at 3 months but this should not be achieved at the expense of tracheal intubation or facemask anaesthesia.
This study has shown a range of tracheal intubations from 36 to 107. We feel it is appropriate to consider that a minimum number of airway procedures are carried out before new-starts can administer anaesthesia without direct supervision. This target should be both achievable and associated with an acceptable level of competence for most learners. In our study, the median number of intubations per trainee was 56. Although data for the learning curve for tracheal intubation are sparse, Konrad and colleagues12 found that the intubation learning curve reached a 90% success rate after a mean of 57 attempts. Mulcaster and colleagues13 found that a 90% probability of a ‘good intubation’ required 47 attempts in non-anesthesia personnel. Similar figures are quoted for other practical procedures. Central venous catheterization is half as likely to result in a mechanical complication if placed by a physician who has performed 50 or more catheterizations.14 Currently in the west of Scotland it is recommended that new-starts should carry out at least 50 tracheal intubations before providing anaesthesia without direct supervision. Perhaps this number should be higher. A target of 60 would be realistic (representing one intubation per day for 3 months, assuming 20 days at work per month) and should confer a degree of competence. New trainees should be encouraged to move between theatres in a suite to maximize experience of tracheal intubation and where possible be allocated to lists with higher patient numbers and turnover.
Competency-based SHO training15 requires adequate training in airway management in the formative months. While individuals will become competent at different rates, this study confirms a widespread concern that SHOs at this important stage may not always be getting enough experience to ensure that slow learners can also achieve competence in these basic skills. Airway training in the first 3 months should have a higher profile; trainees must demonstrate competence in all three basic airway skills before providing anaesthesia without direct supervision. We recommend that training in facemask anaesthesia should be highlighted and that new-start SHOs should carry out a specific number of tracheal intubations.
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Acknowledgments |
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We would like to thank the College Tutors and Senior House Officers who took part in the study.
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Footnotes |
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LMA® is the property of Intavent Ltd. 
Presented at Difficult Airway Society, Leicester, November 26, 2004.
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References |
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1 Moores A and MacLeod AD. Airway management skills: An audit of new-start SHOs. RCA Bull 2003; 22:1113–14
2 Stringer KR, Bajenov S, Yentis SM. Training in airway management. Anaesthesia 2002; 57:967–83[CrossRef][Web of Science][Medline]
3 Underwood SM and McIndoe AK. Influence of changing work patterns on training in anaesthesia: an analysis of activity in a UK teaching hospital from 1996 to 2004. Br J Anaesth 2005; 95:616–21
4 Tomlinson A. Effects of the EWTD on anaesthetic training in the UK. Anaesthesia 2005; 60:96–7[CrossRef][Web of Science][Medline]
5 Yarrow S, Hare J, Robinson KN. Recent trends in tracheal intubation: a retrospective analysis of 97 904 cases. Anaesthesia 2003; 58:1019–22[CrossRef][Web of Science][Medline]
6 Cooper GM. Is the art of airway management being lost? RCA Bull 2002; 14:662–3
7 Clyburn PA. Early thoughts on ‘Why Mothers Die 2000–2002’. Anaesthesia 2004; 59:1157–9[CrossRef][Web of Science][Medline]
8 Mason RA. Education and training in airway management. Br J Anaesth 1998; 81:305–7
9 Alexander R, Hodgson P, Lomax D, Bullen C. A comparison of the laryngeal mask airway and Guedel airway, bag and facemask for manual ventilation following formal training. Anaesthesia 1993; 48:231–4[Web of Science][Medline]
10 Abdalla S and Thomson KD. Away with the LMA? Anaesthesia 1999; 54:1116–17[Web of Science][Medline]
11 Davies PRF, Tighe SQM, Greenslade GL, Evans GH. Laryngeal mask airway and tracheal tube insertion by unskilled personnel. Lancet 1990; 336:977–99[CrossRef][Web of Science][Medline]
12 Konrad C, Schupfer G, Wietlisbach M, Gerber H. Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures? Anesthesiology 1998; 86:635–9[CrossRef]
13 Mulcaster JT, Mills J, Hung OR, et al. Laryngoscopic intubation. Learning and performance. Anesthesiology 2003; 98:23–7[CrossRef][Web of Science][Medline]
14 McGee DC and Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348:1123–33
15 Royal College of Anaesthetists. The CCST in Anaesthesia II. Competency Based Senior House Officer Training and Assessment. A Manual for Trainees and Trainers
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