Journal of ISSN: 2373-6437JACCOA

Anesthesia & Critical Care: Open Access
Volume 4 Issue 3 - 2016
Simulation for Airway Management in a Critical Care Set Up
Rakesh Garg*
Department of Onco-Anesthesiology and Palliative Medicine, India
Received:January 21, 2016 | Published: February 12, 2016
*Corresponding author: Rakesh Garg, Department of Onco-Anesthesiology and Palliative Medicine, Dr Brairch All India Institute of Medical Sciences, Ansari Nagar, New Delhi -110029, India, Tel: +91-9868398335; +91-9810394950; Email:
Citation: Garg R (2016) Simulation for Airway Management in a Critical Care Set Up. J Anesth Crit Care Open Access 4(3): 00142. DOI: 10.15406/jaccoa.2015.04.00142


Airway management remains challenging for any anesthesiologists. It becomes more challenging in a critically ill patient. The essential component of successful airway management requires specialized technical and nontechnical skills along with sound background knowledge and higher-order cognitive skills and behaviors [1,2] (Figure 1). The traditional forms of airway management learning has shown a drift from lecture based teaching to mannequins and handling of equipment in the past. These may be considered only for basic training as these remain static and do not provide clinical feedback of real time situations. There was further change to video based and interactive sessions along with acquisition of skills on mannequins [3,4]. These may be considered only for basic training as these remain static and do not provide clinical feedback of real time situations. But recently with advancement in technology, simulator based learning has emerged as an important tool for airway management [5,6].

The simulators have been used conventionally by pilot training wherein real time scenario and crisis situation is created for management. Similar concept has been recently extended in medical sciences for teaching and training and has found an important role in airway management as well. Simulators are inevitable for learning the technical skills and aids in learning and assessing psychomotor tasks, cognitive and affective skills [1,3,4,7,8]. Simulation practice ensures team dynamics along with application of algorithmic approach for holistic management. Traditionally airway management training was delivered by practicing skills like laryngoscopy, fiberscopy tracheal intubation individually. In real scenario, these individuals skills needs to be choreographed into an systematic approach. We need to have primary approach for airway management, secondary approach, if it fails and also subsequent rescue approaches. These real time airway management may not be possible in airway trainers by learning individual skills. The algorithms have been proposed by various professional bodes for management of airway [1]. The stimulators would help to acquire the skills and judgment of the equipments and techniques required of the algorithm [1]. The simulators in airway management helps in improving psychomotor level (skill training), cognitive level (decision making) or affective level (interacting with peers/coworkers) [1]. The simulators are an important tool for evaluation of efficacy of training and skill retention [1,2,9]. In view of ethical concerns and patient safety, simulator training would become essential prior to interacting with real patients as compared to training on real patients. The simulator available are both partial-task or whole-task trainers and may replicate real time conditions without compromising the patient safety [1]. Though the animal models were initially used for these concerns, but many aspects of real time situations were not feasible in such models [1]. The high-fidelity patient simulation reproduce real-life patient and a similar environment may be created as to be encountered by the learners. Such environment may be considered as sensitizer for the learners for real time stressful situations to handle difficult airway situations in critically ill patient. Unlike real patients, a high-fidelity airway simulator provides various opportunities for different type of airway difficulties and complications. This provides learners an opportunity to perform multiple times under different conditions.

The steps related to airway simulation training in a critical care set up are:

  1. Objective of the simulation: This should be decided prior to start of simulation based on the need of the participants. It should be objectively mentioned and goals ascertained. The level of learning may also be objectively decided.
  2. Simulation scenario-creation and designing: As per the requirement, the scenario needs to be prepared that covers the objective of the airway simulation in the initial step. The scenario should include options/alternatives for management and may be algorithm based which may have been introduced to the participants prior to act. The scenario should decipher the role of each members of the team and evaluation sheet for the trainer as well. The trainer should be well versed with the various flows of the scenario related to airway management and thus required equipments and other accessories also needs to be arranged.
  3. Simulation performance: This is the real act after the stage is set for airway management. The various steps should be predicted by the trainer and positive and constructive inputs and guidance provided through the act. The participants are made aware of the simulation environment and then continued with the simulation drill. The requisite of such simulation is recording of the events that were the initial objectives.
  4. Debriefing and evaluation: This process involves critical appraisal of the simulation keeping in mind the initial objective. This may require a flow chart or video recording based discussion. This should be done in positive and constructive manner and trainer should conduct debrief in a team-building atmosphere.

The presence of trained team improves the success of airway management. The team dynamics needs to be learnt and simulation provides team practice as well. The simulation in airway requires basic elements of team dynamics including clear communication and understanding among team members. The role and responsibilities needs to be clarified and practiced. Team members needs to practice and share their knowledge and expertise in respectful environment. The advantage of expertise of particular skill by a particular individual needs to be kept at advantage or in other words the limitation of the members needs to be appropriately tackled. These all team dynamics elements can be practices on simulation bases airway learning.

The learning of specific training skills like surgical airway, laryngoscopy, fiberscopy or supraglottic airway device placement is important. But its correct selection, its use in specific situations in a timely manner with appropriate team dynamics is also essential for successful patient outcome [4]. It remains to be emphasize airway learning in critical care set up should follow an holistic approach and based on situations and resources available and should be comprise of knowledge acquisition, skill practice and simulation scenario based practice [10].


  1. Nargozian CD (2004) Simulation and air management training. Curr Opin Anaesthesiol 17(6): 511-512.
  2. Hubert V, Duwat A, Deransy R, Mahjoub Y, Dupont H (2014) Effect of simulation training on compliance with difficult airway management algorithms, technical ability, and skills retention for emergency cricothyrotomy. Anesthesiology 120(4): 999-1008.
  3. Mileder LP, Schmolzer GM (2014) Simulation and its role in airway management training. Crit Care Med 42(7): 541-542.
  4. Kennedy C, Cannon EK, Warner DO, Cook DA (2014) Advanced airway management simulation training in medical education: a systematic review and meta-analysis. Crit Care Med 42(1): 169-178.
  5. Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, et al. (2011) Technology-enhanced simulation for health professions education: A systematic review and meta-analysis. Jama306(9): 978-988.
  6. Ilgen JS, Sherbino J, Cook DA (2013) Technology-enhanced simulation in emergency medicine: A systematic review and meta-analysis. Acad Emerg Med20(2): 117-127.
  7.  Mundell WC, Kennedy CC, Szostek JH, Cook DA (2013) Simulation technology for resuscitation training: A systematic review and meta-analysis. Resuscitation 84(9): 1174-1183.
  8. Cook DA, Hamstra SJ, Brydges R, Zendejas B, Szostek JH, et al. (2013) Comparative effectiveness of instructional design features in simulation-based education: Systematic review and meta-analysis. Med Teach35(1): e867-e898.
  9.  Lorello GR, Cook DA, Johnson RL, Brydges R (2014) Simulation based training in anaesthesiology: a systemic review andmeta-analysis. Br J Anaesth 112(2): 231-245.
  10.  Lucisano KE, Talbot LA (2012) Simulation training for advanced airway management for anesthesia and other healthcare providers: a systematic review. Aana J 80(1): 25-31.
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