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Table of Contents
Year : 2019  |  Volume : 35  |  Issue : 3  |  Page : 287-288

Acquiring skills of airway management: The grandpa–granddaughter model!

Department of Anesthesiology and Intensive Care, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India and Airway Management Foundation, India

Date of Web Publication3-Sep-2019

Correspondence Address:
Dr. Rakesh Kumar
C-334, Saraswati Vihar, Delhi - 110 034
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_253_19

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How to cite this article:
Kumar R. Acquiring skills of airway management: The grandpa–granddaughter model!. J Anaesthesiol Clin Pharmacol 2019;35:287-8

How to cite this URL:
Kumar R. Acquiring skills of airway management: The grandpa–granddaughter model!. J Anaesthesiol Clin Pharmacol [serial online] 2019 [cited 2021 May 17];35:287-8. Available from:

As the grandpa runs beside his granddaughter while she rides her bicycle for the first time, he maintains a strict scrutiny on all her actions – from the way she sits to the way she holds the handle to the way she places her feet on the paddles, and keeps repeating the more important steps and nuances – how to place her feet to generate maximum force, when to shift pressure from one foot to the other, how to go uphill, and how to go downhill! He gets tired after two rounds, but the kid forces him into the third. And then she is ready the next morning for many more rounds. No wonder then that on the seventh day she is a fluent driver and is showing the grandpa all the steps he'd told her were important! The same holds true for acquiring every skill.

This issue too has three articles that highlight issues related to training in airway skills.

Boulton et al.[1] present their evaluation of the advanced airway skills and airway training among senior anesthetic trainees in the United Kingdom in the light of Royal College of Anesthetists (RCoA) curriculum and Difficult Airway Society (DAS) guidelines and identify numerous deficiencies in airway competencies and training among them. The time spent in a dedicated airway rotation varied from no rotation to 1 year. Very few had access to an airway skills room, regular high-fidelity simulation training in airway emergencies, or training in airway emergencies with full theater team participation. Manikin-based workshops were the most commonly attended. I am not aware of dedicated airway rotation in any department in our country and the airway training is still mostly on the hapless patients, with departmental exposure to even manikin-based training quite infrequent.

Qazi et al.,[2] on the other hand, present the outcome of a national survey to evaluate the issues around one of the skills, the emergency front of neck airway (more commonly called front of neck access) (FONA) and share findings similar to those of the earlier survey. They found that the in-house FONA training is quite infrequent and rarely mandatory. They also found that only 20% respondents routinely palpated cricothyroid membrane (CTM) during airway assessment and only 10% of these 20% used ultrasound to identify and mark the CTM in cases where it was found impalpable. A picture very similar to most of our institutes as well.

Related closely to FONA is another study by Qasem et al.[3] who present a rather disheartening finding that only 46% of physicians of various specialties (even worse for anesthesia consultants at 40%!) could correctly identify the cricoid cartilage in obstetric patients, thereby reinforcing the suggestion by Qazi et al.[2] regarding ultrasound-guided CTM identification. Our Airway Management Foundation (AMF) team has had similar experience. Having realized long time back that CTM recognition does not come “naturally” to every airway manager, our AMF team incorporates identifying CTM as a mandatory, and very well appreciated and enjoyed, step at both the emergency FONA and PCT workstations.

All these articles suggest various means to maintain one's skill levels high. The suggestions include restructuring of the airway training program and improvements in access to training facilities,[1] regular targeted training in airway ultrasound during routine airway assessments, standardizing difficult airway trolleys across theaters, intensive care unit, and emergency departments to prevent confusion regarding which technique to use when needed (in this case the FONA technique[2]), and the development of training and competency maintenance programs that include correct cricoid cartilage identification.[3]

Qazi et al.'s[2] suggestion to limit the choices seems to indicate that it is better to keep the number of skills and options learnt and made available low rather than having too many choices. Although that may lead to some of the skills being neglected by a department and thus forgotten by its members, others[4] also feel that it is better than the “paradox of choice” or “overchoice” created by complicated algorithms advocating a plethora of airway devices and choices. This “overchoice” may cause errors of omission or “analysis paralysis” during airway crisis. We have also observed that in departments that have multiple airway devices, team leaders sometimes get trapped in the thought process that the less often used device/approach is better than what they are good at but have failed in just once, leading to mismanagement.

While all these authors talk about the ways to acquire and sustain psychomotor or technical skills of airway management, there is a strong case for discussing the nontechnical (cognitive and affective) skills such as the teamwork and leadership skills, and the implementation skill described so well by Chrimes while discussing the Vortex tool.[5] Greenland[4] suggests that nontechnical aspects of difficult airway management should be an integral part of crisis management. Talking about the role of leadership in airway management, he suggests that the junior consultants should train and practice in simulators to improve the nontechnical aspects of their professional role. On the other hand, the senior consultants or “airway experts” should look to streamline teaching of airway management by providing clear goals and a simple framework within which staff can work confidently, and quietly support the least skilled in the department, with a view to providing a clear path toward mastering airway management. The new DAS guidelines[6] also seem to promote nontechnical skills by adding the step of “stop and think” if the Plan B of placing supraglottic airway device succeeds.

Being not a part of our undergraduate or postgraduate teaching, we first learnt the skills like teamwork and debriefing during our ACLS Provider and Instructor Courses. Many of us then practiced these regularly during codes and passed on to other providers/mentees as instructors/mentors. Soon, we found these extremely useful during our day-to-day airway management and airway simulations.

Another aspect of airway skills training that is pertinent, I feel, to every training is that it should be assessment driven. The trainees should be provided with the Checklist to be used during their assessment right at the beginning of their training. This allows them to focus on the more important steps and promotes standardized approach on the part of trainers as well, both during training sessions and during assessment, as we have experienced during the BLS/ACLS Courses. Greenland[4] too, in his editorial accompanying the latest DAS guidelines,[6] suggests that the future anesthetic curricula should be guided by the formal assessment of the skills imparted (including nontechnical “skills”).

Who do you find roaming outside on a nice day, a hot sunny day, a rainy day, and also while it is snowing? Yes, it is that same grandpa–granddaughter duo! She, because she wants to keep repeating the same activity (cycling in this case) again and again; and he, because he is patient enough to keep watching her improve and ready to listen to her when she is teaching him! In short, there are hundreds of “airway experts,” but if you want to learn the technical and nontechnical skills of airway management, find a trainer who has the patience, perseverance, and confidence of a grandparent and you yourself become a small, inquisitive, repetitive child! Best of luck …

  References Top

Boulton AJ, Balla SR, Nowicka A, Loka TM, Mendonca C. Advanced airway training in the UK: A national survey of senior anesthetic trainees. J Anaesthesiol Clin Pharmac ol 2019;35;326-32.   Back to cited text no. 1
Qazi I, Mendonca C, Sajayan A, Boulton A, Ahmad I. Emergency front of neck airway: What do trainers in the UK teach? A national survey. J Anaesthesiol Clin Pharmacol 2019;35;318-23.  Back to cited text no. 2
Qasem F, Khalaf R, Sebbag I, Lavi R, Jones PM, Singh S. Efficacy of surface landmark palpation for identification of the cricoid cartilage in obstetric patients: A prospective observational study. J Anaesthesiol Clin Pharmacol 2019;35;335-9.  Back to cited text no. 3
Greenland KB. Art of airway management: The concept of “Ma” (Japanese: when “less is more”). Br J Anaesth 2015;115:809-12.  Back to cited text no. 4
Chrimes N. The Vortex: A universal “high-acuity implementation tool” for emergency airway management. Br J Anaesth 2016;117:i20-7.  Back to cited text no. 5
Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.  Back to cited text no. 6


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