Simulation Training for Advanced Airway
Management for Anesthesia and Other
Healthcare Providers: A Systematic Review
Karen E. Lucisano, CRNA, MSN
Laura A. Talbot, RN, EdD, PhD, GCNS-BC
We studied the current literature on human patient
simulation for preparing anesthesia and other health-
care providers for advanced airway management. A
systematic review was conducted of articles published
between 1990 and 2009 on advanced airway manage-
ment for patients undergoing anesthesia and patients
who are not. The search used 4 electronic databases:
Cumulative Index to Nursing & Allied Health Litera-
ture, MEDLINE, PsycINFO, and Web of Science.
We included 34 articles in the analysis; 15 were
experimental or quasi-experimental designs, 8 de-
scriptive studies and reports, and 11 analyses of
equipment or technique evaluations using simulation.
The majority of the studies included simulation educa-
I
nability to secure the airway during the induction
phase of a general anesthetic has the potential for
substantial morbidity and mortality. Comorbid con-
ditions likely to pose a substantial risk of hypoxic
injury during induction include pregnancy, multiple
trauma, and obesity. Obesity is of particular concern
because it increases the risk of difficult airway in addition
to reducing the functional residual capacity and increas-
ing metabolism, ultimately leading to a reduction in the
time a person can tolerate hypoxia. In the United States,
more than 30% of adults and 15% of children are obese.1
This high prevalence of obesity and the need to act rap-
idly and efficiently to ensure an uninterrupted supply
of oxygen have led to the need to ensure that anesthesia
providers are competent in the knowledge and technical
skills of difficult airway management.
In an effort to improve outcomes, the American
Society of Anesthesiologists has adopted an algorithm
that can be followed when an anesthetist is unable to
establish an airway using traditional methods. However,
despite these guidelines, malpractice claims related to
failure to secure the airway persist.2
Typically, novice practitioners learn airway manage-
ment on real patients using a bedside apprentice model.
Exposure to real patients is essential, but substandard
performance can put patients at risk, especially when
traditional airway management is ineffective and an
alternative approach is urgently needed. Even seasoned
www.aana.com/aanajournalonline.aspx AANA Journal
tion evaluation for a variety of medical, nursing, and
allied health providers and students. Only 6 studies
addressed the use of simulation as an educational or
evaluation tool to enhance training of anesthesia pro-
viders in difficult airway management. Those studies
included analyses of different types of training and
the perceived value of simulated training, and evalu-
ations of equipment. Few studies have analyzed the
effects of this modality on trainer skills and patient
safety. There is a clear need for well-designed studies
to examine these effects.
Keywords: Difficult airway management, general anes-
thesia, patient safety, simulation training.
practitioners require recurring practice to hone their
skills for rapid resolution. To avoid the risk of harming
patients, a structured simulation training protocol may
be used to prepare anesthesia providers for difficult
airway management.
Human patient simulation offers the ability to provide
anesthesia students and providers a structured and stan-
dardized experience and to demonstrate proper manage-
ment of uncommon but high-risk events with no danger
of injury to a patient. This article reviews the literature
on human patient simulation for training anesthesia and
other healthcare providers for advanced airway assess-
ment and management.
Search Strategy
We used 4 electronic databases: Cumulative Index to
Nursing & Allied Health Literature (CINAHL; January
1, 1995 to September 25, 2009), MEDLINE (January 1,
1990 to September 25, 2009), PsycINFO (January 1, 2000
to September 25, 2009), and Web of Science (January 1,
1990 to September 25, 2009). For the CINAHL search,
we used the following search terms: “airway manage-
ment” and “simulation.” This search obtained 16 “hits.”
We searched MEDLINE using 2 indexes: the PubMed
index, using the search terms “airway management” and
“simulation” and “anesthesia,” which generated 44 hits,
and by the CSA Illumina index, using the search terms
“airway management” and “simulation,” which generated
 February 2012  Vol. 80, No. 1 25
33 hits. It is interesting that when we added “anesthesia”
to the search term in this index, the number of articles
returned fell to 6. PsycINFO was searched with the terms
“airway management” and “simulation” and produced 4
hits. Finally, we searched Web of Science using “airway
management” and “simulation” and received 126 hits; we
then refined the subject area to “anesthesia” and received
32 hits (Figure).
We independently applied the eligibility criteria for
the review to the methods section of each article from
the selected databases. The criteria were as follows: (1)
experimental or quasi-experimental design, (2) inclusion
of a simulated advanced airway management training
process for anesthesia or other healthcare providers, and
(3) clearly stated study objectives with measured out-
comes. We engaged in detailed discussions to resolve any
disagreements on articles for study inclusion.
Results
A total of 129 studies were considered for review; 41
were duplicates, and 1 was not available in English. The
87 nonduplicated articles were screened for possible
inclusion in the review based on the predetermined in-
clusion criteria: use of an experimental or quasi-experi-
mental design, a simulated advanced airway management
training process for anesthesia or other healthcare pro-
viders, and clearly stated study objectives with measured
outcomes. Of the 87 studies, 34 were considered further.
During this phase, the full article was acquired and re-
viewed in a more detailed evaluation. Of the 34 studies,
15 were randomized controlled trials,3-17 8 were descrip-
tive studies,18-25 and the remaining 11 studies used simu-
lation as a tool to evaluate equipment or techniques or
a specific simulator’s level of fidelity.26-36 In accordance
with the predetermined inclusion criteria, 15 articles3-17
were included in this review (see Figure).
• Study Samples. The study samples varied widely.
They included physician and paramedic teams,7 re-
spiratory therapists,6 flight nurses and paramedics,11
pediatric residents and fellows,4 medical and dental
residents,5,9,10,12,15 nursing students, and other students.8
There were 6 studies that included anesthesia residents
and/or anesthesia providers5,13-17 (Table 1). Samples
ranged from 12 to 120 subjects.
• Study Purpose. Study purposes included the following:
1. An analysis of the effects of simulation on single or
multiple airway task completion7,11,12
2. A comparison of the effects of simulation training
over time 3,6,16
3. An analysis of the effects of different types of simu-

and and
Total articles
= 129

MEDLINE via MEDLINE via CSA Web of PshycINFO CINAHL

PubMed, n = 44 n = 33 Science n=4 n = 16
AM & S & A AM, S n = 32 AM, S AM, S
AM, S
Total nonduplicated
articles = 87

MEDLINE via MEDLINE via CSA Web of PshycINFO CINAHL

PubMed, n = 42 n = 11 Science n=4 n = 14
n = 16

Abstract screen/review
Delete 1 non-
English article

34 Articles further analyzed

15
8 11 Equipment or
Randomized controlled
Descriptive studies technique evaluations
trails

15 Studies included in review

Figure. Graphic of Search

Abbreviations: CINAHL, Cumulative Index to Nursing & Allied Health Literature; CSA, CSA Illumina.

26 AANA Journal  February 2012  Vol. 80, No. 1 www.aana.com/aanajournalonline.aspx

 Type of airway Outcome measures
Study Purpose Sample Design simulation or results Conclusion

Johnson et al,17 Exploration of how 22 first-year anes-Baseline assessment of Pediatric and adult No. of correct diagnoses; All metrics improved in both groups; experi-
2008 principles of part thesia residents; in-training examination unanticipated difficult weighted task scores; mental group able to complete 9% more
task training (PTT) score, US Licensure
control group, stan- airway and other no. of correct responses tasks than control group; experimental
and variable priority dard didactic and Exam I-III; performance respiratory events to comprehension ques- group showed greater increase in correct
training (VPT) would simulation-based in 7 simulation-based tions; composite NASA- diagnosis from baseline (P = .249); per-
improve anesthesia training (n = 11); scenarios, graded at TLX scores (perceived ceived workload decreased by 30% from
residents’ adverse experimental group,the beginning and end physical and cognitive baseline in both groups
airway manage- standard and didac-of 1 year of training; workload)
ment and respira- tic training with scenarios were time
tory events addition of PTT andlimited; performance
evaluated by 2 indepen-
VPT training (n = 11)
dent, blinded observers
Pott and Determine whether Novice users of Bul- Prospective descriptive Intubation with Bul- Competence evaluated Course completed in ≤ 21 min, successful
Santrock,5 2007 a complex motor lard laryngoscope study lard laryngoscope; via a checklist; time to at first attempt to intubate, assembled and

www.aana.com/aanajournalonline.aspx
skill can be taught (n = 28); attending instruction by Power- intubation, total time to successfully intubated in ≤ 5 min; showed
without the use of anesthesiologists, Point (Microsoft, prepare scope and intu- structured self-learning programs and mani-
active expert partici- anesthesia resi- Redmond, Wash- bate, and time used to kin simulation can be effective methods to
pation dents, and medical ington) presentation study the slideshow and teach a complex motor skill
students not experi- prepared by experts; practice
enced in use of Bul- Bullard laryngoscope,
lard laryngoscope endotracheal tube,
and manikin head
also used
Goldmann and Test the hypothesis Medical residents, Observational study Intubation of an adult Time to intubation Novices and experts improved time to
Steinfeldt,15 that a virtual reality novice nontraining using FOI intubation before and following a intubation VR FOI, only significant in novice
2006 (VR) airway simula- residents who did 4-d training period; time group (P < .001); in cadaver group, time to

AANA Journal

tor can be used to not use the VR sim- measured for an adult intubation the same in novice training and
teach fiberoptic ulator (n = 4); nov- virtual reality FOI sce- expert groups but longer in novice nontrain-
intubation (FOI) ice training group, nario and a fresh human ing group (P < .001); VR airway simulator
skills all residents who cadaver at 2 wk after seems to offer effective tool for training in
used VR simulator training FOI and may offer tool for assessment of
for 1-wk period (n = readiness before trainees attempt technique

February 2012
11); experts, attend- on live patients


ing anesthesiolo-
gists (n = 4)

Mackenzie et Compare perfor- 48 trauma patient Nonexperimental, Performance defi- 28 performance defi- Compared with video analysis, other types
of reports missed the majority of deficien-

Vol. 80, No. 1

al,14 1996 mance of deficien- encounters observational study ciencies in airway ciencies in 11 cases
cies of airway man- management as cies; most frequent deficiency,

27
continues on page 4
 continued from page 3

28
Type of airway Outcome measures
Study Purpose Sample Design simulation or results Conclusion

agement captured identified by the by video analysis; no per- failure to adhere to operating room pro-
by 3 types of self- anesthesia record, formance deficiencies cedure; use of video analysis to identify
report with those the anesthesia quality noted; 2 deficiencies performance deficiencies and their factors;
identified by video assurance report, and noted on the anesthesia use of a no-fault self-reporting mechanism

AANA Journal

analysis posttrauma treatment record; PTQ identified may be useful
questionnaire (PTQ) 8 of 11 cases in which
compared with video deficiencies were noted
analysis by video analysis
Goldberg et Evaluate the risk 40 patients ran- Controlled prospective Intubation using air- Risk assessed by No significant differences between the
al,13 1990 of a simulation domly assigned to study way adjunct changes in vital signs, groups in any outcome indicators except

February 2012
drill designed to 2 groups: control oxygen saturation, EI; 5 EIs in the simulation group and none


increase the skill group (n = 20), ischemia, arrhythmias, in the control group (P = .001); hazards
of anesthetists in intubation by stan- esophageal intubation posed by EI should be considered before
dealing with unex- dard techniques; (EI), or pulmonary aspira- simulation drill is replicated
pected difficult simulation group tion
intubations (n = 20), intubation

Vol. 80, No. 1

of a difficult airway
simulated and per-
formed with the
aid of endotracheal
introducer
Kuduvalli et Measure the 21 British anesthe- Prospective case- 2 scenarios in adult Management of scenar- CI scenario: Significant increase in time
al,16 2008 effects of training tists control interventional simulated patients: 1, ios scored by 1 observer to insert laryngeal mask airway (LMA) or
on compliance with study; performance in cannot intubate, can- based on “ideal” man- intubating LMA at 6 - 8 month interval (P
national guidelines 2 scenarios measured not ventilate (CICV); agement plan derived < .05); significant reduction in deviations
for management of at baseline and 6-8 2, cannot intubate, from DAS guidelines from guidelines at 6 - 8 wk only; CICV sce-
unanticipated dif- wk and 6-8 mo after can ventilate (CI) nario: Significant, sustained improvement
ficult airway and/ training on the Difficult in technical skills of cricothyroidotomy (P
or ventilation, more Airway Society (DAS) < .05), no significant reduction in mean
specifically, effect algorithm duration of oxygen saturation from base-
of formal training on line, which was no longer present at 6-8
performance over mo; significant reduction in deviations
time from guidelines at both times (P < .05);
In both scenarios, sustained reduction in
improper use of equipment (P < .05)

Table 1. Review of Clinical Research Studies of the Use of Simulation as an Educational or Evaluation Tool to Enhance Training of Anesthesia Providers
in Difficult Airway Management

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lators and techniques on learning13
4. An analysis of the effects of nonhuman interfaced
simulation5,8,15
5. A study of the effects of an actual human-based
simulation4,9,10,17
6. An evaluation of the types of methods used to assess
performance deficiencies14
• Outcome Measures. Outcome measures varied greatly
and included the following:
1. Single and multiple measures of performance com-
pared with a predetermined checklist3-7,9,10,12,16,17
2. Time to completion of a specific task4-7,15 and
number of attempts8,13
3. Subjective and/or self-perceived value of the simu-
lated experience11
4. Measurement of efficient and nonefficient time4
5. Analysis of performance based on generally accepted
guidelines using several different reporting modalities14
Types of Airway Management Evaluated
Specific types of airway management evaluated included
prehospital airway management,7,11 fiberoptic intuba-
tions,4,6,15 assessment skills and airway management of
unanticipated adult and pediatric difficult airways,16,17
establishment of a mask airway during an arrest sce-
nario,3,8,9-12 use of a specific intubation laryngoscope,5
airway management of trauma patients,14 and the use of
an airway adjunct.13
• Difficult Airway Algorithm (DAA). Our review failed
to identify a study of the effects of simulation on skill
improvement and retention for management of a patient
with a difficult airway using the nationally recognized
DAA from the United States. We identified 1 such study
in the United Kingdom. Kuduvalli et al16 evaluated per-
formance using guidelines developed by the Difficult
Airway Society of the United Kingdom for management
of unanticipated difficult intubation in adult nonobstetric
patients. The aim of the study was to evaluate the decay
of the effects of training over time. In this case-control
study, all participants underwent simulation-based train-
ing. The authors used a structured approach and found
that training effects were sustained at a 6- to 8-week
retest but not at the subsequent 6- to 8-month retest.
They also found a reduction in the misuse of equipment
with training. They concluded that training should be
repeated at 6-month intervals or less.
Discussion
Simulation has been used for airway management train-
ing by multiple medical and allied health groups. Study
designs to evaluate the use of this training and teaching
method have varied widely (Table 2). Despite their het-
erogeneity, the outcomes of these studies support the
effectiveness of this training modality. Thus, findings of
this systematic review confirm that simulation may be
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an effective tool to teach airway management skills and
provide support for techniques that may be used in the
DAA for anesthesia providers.4,7-12
Few studies established a valid method of evaluating
the potential or actual effects of this training on patient
safety and the transition of skills from the laboratory to
the clinical setting. Of the outcome variables used to
detect learning in the simulation laboratory included in
the review, most used objective measures of performance,
including a weighted and nonweighted checklist, and/or
time to completion of a task. The ways these skills trans-
lated to bedside care and patient safety were investigated
by only 1 study. Crabtree et al6 studied the correlation
between simulated performance of fiberoptic intubation
and clinical skills. Although they did not find a signifi-
cant correlation, they believed their outcome measure of
“time to completion” not to be sensitive enough to detect
improvement in overall skill performance.
Simulation can include the use of whole body, part
trainers, virtual reality, and computer-based trainers.
The task being taught, the availability of trainers, and
time flexibility seem to be the most important variables
to consider in developing the most effective simulation
design. For example, Kuduvalli et al16 examined the
effects on management of a patient with a difficult airway
using whole-body, scenario-based simulation training for
a group of nonnovice anesthesia providers. The purpose
of the training was to achieve competency in complex de-
cision making and advanced skills. Fidelity to the actual
clinical environment was considered key in developing
the specifics of the simulated scenario. Pott and Santrock5
studied the effectiveness of simulation in developing a
single complex motor skill (Bullard laryngoscope, Gyrus
ACMI, Southborough, Massachusetts). Self-instruction
via a PowerPoint (Microsoft, Redmond, Washington)
presentation and a part task trainer were used, and all
learners were deemed competent after training.
Limitations of the Review
As with all systematic reviews, the accuracy of a lit-
erature review depends on the appropriate use of search
terms and search procedures for the databases searched.
Although we endeavored to use the broadest search terms
and worked closely with a librarian, if not described
fully in the abstract, some relevant studies might have
been missed. Standardized outcome criteria by which to
measure the effects of training are notably dissimilar in
the studies.
Recommendations
Additional research is needed to further evaluate the use
of simulation as a tool to teach advanced airway manage-
ment to anesthesia students and current practitioners.
The DAA has been suggested as a potential basis on
which to design the simulation and subsequent evalu-
 February 2012  Vol. 80, No. 1 29
 Design Study
Sample Physician and paramedic teams 7
Respiratory therapists 6
Flight nurses and paramedics 11
Pediatric fellows 4
Medical residents and dental residents 9, 10, 12, 15
Nursing, dental, and other students 3, 8
Anesthesia residents and practitioners 5, 13-17
Purpose Effect of simulation on airway task completion 7, 11, 12
Comparison of effects of simulation training over time 3, 6, 16
Analysis of effects of learning 13
Analysis of effects of nonhuman interfaced simulation 5, 8, 15
Effects of human-based simulation 4, 9, 10, 17
Evaluation of methods used to assess performance deficiencies 14
Outcome variables Single and multiple measures of performance based on checklist 3, 7, 9, 10, 12, 16, 17
Time to task completion/number of attempts 4-7, 15/8, 13
Subjective value of simulation training 11
Measurement of efficient and nonefficient time 4
Analysis of performance using different reporting modalities 14
Type of airway management Prehospital 7, 11
evaluated Fiberoptic intubation 4, 6, 15
Assessment skills and management of unanticipated adult and 16, 17
pediatric difficult airways
Mask airway during arrest 3, 8, 9-12
Nontraditional intubation equipment 5
Airway management in trauma patients 14
Airway adjuncts 13

Table 2. Comparison of Overall Design of Human Patient Simulation Studies

ation of performance. Management of a patient with a
difficult airway, whether anticipated or not, is not a
matter of if; it is a matter of when. Yet exposure to this
emergency clinical event is sporadic, as are opportunities
for teaching during these events. High-fidelity human
patient simulation would seem to be an ideal method to
provide educational opportunities, including teaching
and practice, yet studies to investigate this method are
lacking.
If future studies support the use of human patient
simulation as an adjunct to didactic training for manage-
ment of a patient with a difficult airway, educators could
develop a standardized curriculum and outcome criteria
that are preprogrammed (including simulator program-
ming) and learner-centered. Virtual reality simulators
programmed with standardized teaching (knowledge),
training (skill), and performance benchmarks may be at-
tractive to students and educators.
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AUTHORS
Karen E. Lucisano, CRNA, MSN, is a doctoral student in the College of
Health and Human Services, University of North Carolina at Charlotte,
Charlotte, North Carolina. Email: kellis1@uncc.edu.
Laura A. Talbot, RN, EdD, PhD, GCNS-BC, is professor and Dean
Covard distinguished professor of nursing, in the School of Nursing, Uni-
versity of North Carolina at Charlotte. Email: ltalbot@uncc.edu.
 February 2012  Vol. 80, No. 1 31