key: cord-0916541-ge35p7bc authors: Hickman, John; McNarry, Alistair F.; Kelly, Fiona E. title: Practical Strategies for Delivering Airway Training in the COVID-19 Era date: 2021-05-14 journal: Br J Anaesth DOI: 10.1016/j.bja.2021.05.004 sha: 276ac07ea9e4ebd06eefef0d2d6e41ef1535d879 doc_id: 916541 cord_uid: ge35p7bc nan precautions will be in place for some time to come and that this issue will be relevant for the foreseeable future. 9 The fall in airway training opportunities is multifactorial; here we consider UK practice as an example, although the same is likely to apply in many countries. COVID-19 airway guidelines recommend that the most experienced clinician acts as first intubator and that the number of staff present at intubation is minimised. [1] [2] [3] [4] 10 The Intubate-COVID study reported that the most senior airway manager intubated in 70% of cases. 11 Many anaesthetic trainees were redeployed to intensive care units (ICUs), resulting in reduced time in theatre: in the UK in December 2020, one in six anaesthetists were unavailable to work in operating theatres. 12 In the UK, almost half of NHS elective operations were cancelled, and worldwide an estimated 28 million cases suffered disruption in the first three months of the pandemic. 13 Many anaesthetists have increased their use of regional anaesthesia to avoid perceived aerosol-generating procedures 9, 14 and reduced their use of supraglottic airways. 15 Personal protective equipment hampers communication between trainer and trainee, making feedback and discussion much more challenging. 9 Finally, widespread cancellation of courses, conferences and workshops has limited hands-on procedural practice. Videolaryngoscopes have been shown to be better teaching tools than direct laryngoscopes, 16 with advantages applicable to all grades of trainee. Novice intubators can be taught to intubate using a videolarygoscope with a blade such as a Macintosh that also enables direct laryngoscopy, with the trainee and trainer using the shared view on the videolaryngoscope screen to identify the relevant structures and allow the trainee to intubate the patient with minimal assistance. Once a trainee is felt to be ready, intubation training can be continued with the videolaryngoscope screen turned away from the trainee or the screen covered. This ensures that the trainee learns direct laryngoscopy skills under direct supervision, J o u r n a l P r e -p r o o f with the facility for immediate assistance, and maximises the trainee's opportunity to complete the intubation alone. For more senior trainees, a videolaryngoscope enables them to take on more challenging cases while being coached in real time, and allows them to learn the (different) technique necessary for using a hyperangulated blade videolaryngoscope. 17 A sign of adaptation of standards, in June 2020 the UK Royal College of Anaesthetists (RCoA) accepted that videolaryngoscopes (with a Macintosh-shaped blade) could be used to teach direct laryngoscopy to trainees undertaking their Initial Assessment of Competence, provided that direct laryngoscopy is demonstrated in a simulated environment. 18 Many COVID-19 airway guidelines emphasise videolaryngoscopy to improve patient and intubating team safety. 1-4 1a Videolaryngoscopy can increase first-pass intubation success, 17, 19 reduce failures, 19 increase the distance between the intubator and the patient's airway 20 and mitigate some of the impediments posed by personal protective equipment. 21 Use of a videolaryngoscope with a screen discrete from the blade is associated with improved teamwork, communication and 'flattening of the hierarchy' within the intubating team. 22 The videolaryngoscope has changed from being primarily an airway rescue device to being increasingly advocated as the first-choice device in more recent guidelines. 1, 2, 9, 23 In a recent report, 76% of intubations of COVID-19 patients during March-June 2020 were performed using a videolaryngoscope as the first-choice device, with 90% first-pass success; 11 this is higher than previous reports of 80% in other critically ill cohorts undertaken without personal protective equipment. 1 Increased videolaryngoscope availability and use offers a training opportunity for all staff groups, especially for more junior trainees and anaesthetic assistants 17 working in settings where patients have been screened for COVID-19 and preoperatively self-isolated, while ensuring that the 'first attempt at intubation is the best attempt.' 16 Expertise with hyperangulated videolaryngoscope blades can be gained when managing airways predicted to be straightforward, ensuring that all staff are familiar with the required skills. 17 staff or less at any one time; using an on-line booking system rather than staff 'dropping in' or waiting together in large groups; rotating groups in a one-way manner; extra time to allow equipment cleaning between groups; using digital rather than paper attendance registers, feedback forms, handouts and certificates of attendance to improve infection control. Flipped classroom learning involves students studying on-line prior to attending workshops in person to reduce face-to-face training time. 29 Training opportunities for awake tracheal intubation have been especially limited during the pandemic, and the portable ORSIM® bronchoscopy simulator has been shown to be useful for addressing this. 30 Peer viewed simulation using multiple cameras enables trainees to join a simulation training session via remote link from distant safe sites. Trainees can watch a small group of colleagues taking part in a scenario and learn from their simulation experience, 31 take part in peer-led debriefing and benefit from reflective learning about both technical and non-technical skills. Such sessions and the debrief can be recorded, if it is emphasised that this is optional and with appropriate informed participant consent and controlled access, enabling learning to be shared by those not able to attend in real time. Regular virtual Mortality and Morbidity (M&M) meetings have been successfully run by many departments. As well as providing a chance to discuss clinical cases, such meetings allow trainees to keep in touch with colleagues, including those who are shielding, and many have commented on the beneficial effect on their well-being (Millinchamp F, personal communication, 2021). Regional In summary, airway training opportunities for all anaesthetists have greatly changed during the pandemic, but this does not mean that airway training cannot be delivered. As the American author Napoleon Hill said "in every adversity lies the seed of an equal or greater opportunity." It is possible that, by embracing novel concepts and maximising all airway training opportunities, many aspects of airway training may even be improved. All authors contributed equally to the preparation of this editorial. 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Tea trolley' difficult airway training Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults Stake holder brief issue 13 A national survey of practical airway training in UK anaesthetic departments Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Evaluating the ORSIM® simulator for assessment of anaesthetists' skills in flexible bronchoscopy: aspects of validity and reliability Pop-up simulation suite utilizing Zoom videoconferencing World Airway Management Meeting (WAMM) airway training videos. Available from The authors would like to thank Tom Cope for providing information about the regional hybrid airway course that he organised.