Anaesthesia, 2006, 61, pages 739–742 doi:10.1111/j.1365-2044.2006.04708.

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Basic airway management by junior doctors: assessment

and training on human apnoeic subjects in the anaesthetic
room*
K. Kidner1,3 and A. S. Laurence2
1 Anaesthetic Specialist Registrar, 2 Consultant in Anaesthesia, Department of Anaesthesia, Lancashire Teaching
Hospitals NHS Trust, Preston PR2 9HT, UK
3 Current position: Consultant anaesthetist, Lancashire Teaching Hospitals NHS Trust

Summary
We assessed the airway management skills of 20 junior doctors on patients in the anaesthetic room,
using a self-inflating bag with digital flowmeter to measure exhaled tidal volume. Following
induction of anaesthesia the junior doctor attempted to ventilate the patient’s lungs with five
breaths. If two of these breaths were > 250 ml the assessment was completed. If not, a period of
instruction was given followed by a further five-breath assessment. Eight doctors did not need
further training; of these, six were senior house officers and seven had been on an Advanced Life
Support course. Twelve doctors required instruction and re-assessment. Four were senior house
officers and two had been on an Advanced Life Support course. They showed some improvement
following the instruction period but never reached the standard of the other eight. Validated
courses improve resuscitation skills but hands-on training in the anaesthetic room can also be of
benefit in maintaining these skills.
. ......................................................................................................
Correspondence to: Dr Karen Kidner
E-mail: karen.kidner@lthtr.nhs.uk
*Presented at the Anaesthetic Research Society Meeting on April 2002
in Sheffield, United Kingdom.
Accepted: 3 May 2006

Resuscitation training is variable between medical

Methods
schools, but all hospitals have mandatory resuscitation
training for all newly appointed medical staff. These in- Following Local Ethics Committee approval, patients on
house courses are intended to give junior doctors a whom skills were to be demonstrated were recruited.
chance to learn airway management and other resuscita- They were undergoing elective surgery and were of ASA
tion techniques and then practice them on mannequins to 1 or 2 status. They gave signed, informed permission for
a basic minimum standard. In addition, many doctors the assessment and training to be undertaken on them
attend Advanced Life Support (ALS) and similar courses following their induction of anaesthesia. Junior doctors
that are now considered to be a desirable component for of house officer and senior house officer (SHO) grade
training in most hospital specialities. in specialties other than anaesthetics and intensive care
However, there is still great variability in airway medicine were recruited for assessment of their airway
management at cardiac arrests within hospitals [1, 2]. management skills, and contact details obtained so that
Our aims were to see how effective junior doctors were they could be informed when a suitable patient was going
in airway management by assessing these skills not on a to be anaesthetised.
conventional mannequin, but using an unconscious Immediately prior to undertaking the assessment, the
human subject following induction of anaesthesia. We doctors were asked when their last resuscitation training
also wanted to ascertain whether a brief period of ‘hands had been and whether they had attended an ALS or
on’ training would improve effectiveness of airway similar course. They were also asked about their confid-
management. ence in airway management skills.

2006 The Authors

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2006 The Association of Anaesthetists of Great Britain and Ireland 739
K. Kidner & A. S. Laurence Æ Airway management by junior doctors Anaesthesia, 2006, 61, pages 739–742
. ....................................................................................................................................................................................................................

Following the application of full monitoring and pre- Exhaled tidal volumes of five attempted breaths were
oxygenation of the patient in the anaesthetic room, noted, along with the use of any airway manoeuvre. If
anaesthesia was induced with propofol and fentanyl. The two exhaled breaths out of these five were greater than
junior doctor was thus presented with an unconscious, 250 ml, the assessment was completed. However, if it was
apnoeic and well-oxygenated patient. They were given a unsatisfactory, a brief period of instruction was given; the
self-inflating non-rebreathing system with a reservoir bag doctors were shown the chin lift ⁄ head tilt technique and
to which a digital flowmeter was attached, set to read how to hold the mask correctly. This was followed by a
exhaled breath-by-breath volume (Fig. 1). The bag was further five-breath assessment. Anaesthesia for the patient
connected to the gas supply from the anaesthetic then proceeded as originally planned. The whole assess-
machine, set to a flow rate of 10 l.min)1 oxygen along ment and training period was expected to take no longer
with inhalation agent to ensure that the patient remained than 2 min.
anaesthetised. Routine patient monitoring was main- Exhaled tidal volumes were analysed using paired
tained throughout. No other resuscitation equipment was (Wilcoxon) and unpaired (Mann–Whitney) non-paramet-
presented to the subject, although the full array of Guedel ric tests as appropriate.
airways, laryngeal masks, tracheal tubes and laryngoscopes
were available and in sight on the anaesthetic machine.
Results
Prior to the testing the doctor had been told that this
equipment was available and that they could ask for it at A total of 30 patient subjects were recruited, although not
any time. all were used for the assessment due to problems with
co-ordinating their time of operation with the time when
the medical subjects were free to come to theatre. This
wastage of patient subjects had been expected.
Twenty junior doctors were recruited to the study, of
which nine were pre-registration house officers and the
remaining 11 SHOs. One house officer and seven SHOs
had attended an ALS course.
During the airway assessment, no patient’s SaO2 fell
below 98% at any time and every medical subject
obtained a measurable exhaled breath over the test
period. A mean total exhaled volume of 249 ml was
attained from the first five breaths (n = 20, range 0–821).
Eight doctors were considered satisfactory, with a mean
breath volume of 501 ml and mean 5th breath of 608 ml;
of these, seven were SHOs, all but one of whom had
attended an ALS course.
The remaining 12 doctors were considered to be poor
(5th breath mean 69 ml) and were therefore given a brief
period of training and a further assessment; four were
SHOs and only two had been on an ALS course.
Following the training period, these 12 doctors then
achieved a mean breath volume of 237 ml from the
second five breaths. There was a considerable improve-
ment following the training period (10th breath mean
320 ml), compared to their 5th breath prior to retraining
(p = 0.0075, paired Wilcoxon). However, their 10th
breath was still significantly less than the 5th breath of the
eight doctors who did not require retraining (p = 0.0075,
Mann–Whitney). Figure 2 shows every exhaled breath
produced by each subject and Table 1 summarises the
results.
Very few doctors used any additional airway man-
oeuvres apart from chin lift ⁄ head tilt. This was only used
Figure 1 Self-inflating bag with spirometer. by nine out of the 20 doctors, seven of whom were

2006 The Authors

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2006 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia, 2006, 61, pages 739–742 K. Kidner & A. S. Laurence Æ Airway management by junior doctors
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900
Open -non ALS

Exhaled tidal volume (mls)

800
700 Closed -ALS trained

600
500
400
300
200
100
0
Figure 2 Exhaled breath-by-breath for 1 2 3 4 5 6 7 8 9 10
each subject. Breath number

Table 1 Mean exhaled tidal volumes in ml (range).
All,
Breath number n = 20
1st breath 204 (14–597)
5th breath 285 (0–821)
Average breath 1–5 248 (8–606)
10th breath
Average breath 6–10
Average all breaths 296 (34–607)
doctors who did not require any further retraining. Most
doctors (17 ⁄ 20) said they felt confident about their ability
to maintain an airway prior to testing but few seemed
to know what to look for to see whether they were
delivering effective ventilation or not.
Discussion
We have demonstrated that the standard of airway
management in a group of pre-registration house officers
and SHOs was satisfactory in eight of the 20 doctors
assessed by measuring the volume of each exhaled breath.
We are confident that our measured breath volumes were
actually delivered. By measuring exhaled breath, any
leakage around the facemask (which may have been
common due to poor mask seal) would have resulted in
loss of exhaled volume, so actual exhaled breath would
have been the same or larger than the volume we
measured in all cases.
We made no attempt to control the age or airway
difficulty of the subjects, other than that they were ASA 1
and 2 patients and were all anaesthetised by the same
anaesthetist using a standard technique.
Even the poorest-performing doctor achieved a total
exhaled total volume of 125 ml over five breaths (after
retraining). This typically took half a minute, so we can
assume that our subjects could have received at least
250 ml per minute. If this was near 100% oxygen, this
might sustain life for about a minute, assuming a basal
oxygen consumption of around 250 ml.min)1 [3]. We
Non retraining, Retraining, also chose a figure of 250 ml for each acceptable breath. If
n=8 n = 12
a single exhaled breath of 250 ml is achieved twice in a
358 (82–597) 103 (14–267)
minute, this should be sufficient, if not ideal, to sustain
609 (251–821) 69 (0–212) oxygenation until more experienced help arrives or
501 (195–607) 82 (8–153) intubation is achieved. It should also produce a visible
320 (0–724)
237 (25–597)
movement of the chest.
501 (195–606) 160 (34–277) Other workers have chosen larger tidal volumes. The
American Heart Association recommended tidal volumes
of 800–1200 ml using an adult self-inflatable bag [4];
however, it was recognised that this would produce high
peak airway pressures which could cause gastric insuffla-
tion and potential barotrauma. The European Resuscita-
tion Council recommended a tidal volume of 500 ml in
an unintubated patient as a good compromise to provide
reasonable ventilation but reduce stomach inflation [5, 6].
Wenzel et al. [7] demonstrated that even smaller tidal
volumes of 365 ± 55 ml in adults using a paediatric
resuscitation bag maintained good oxygenation and
carbon dioxide elimination whilst reducing peak airway
pressure and the risk of gastric insufflation and its potential
complications.
Only nine of 20 doctors used any airway devices or
manoeuvres, apart from chin lift ⁄ head tilt. This was
despite being told that Guedel airways were available if
they wished to use them. One subject held the mask
upside down and few looked for chest movement to see if
their efforts were effective. The spirometer was not visi-
ble to them during the assessment. Procedures such as
positioning the head, chin lift and the use of a Guedel
airway are fundamental manoeuvres to assist airway
management in ALS training [8].
Previous attendance on an ALS course was associated
with a considerably better performance at airway man-
agement in our study. We cannot, however, be certain if
this is as a result of skill attained on the course, or because
they were generally more senior and experienced doctors,
as all but one of the ALS attendees were SHOs.

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2006 The Association of Anaesthetists of Great Britain and Ireland 741
K. Kidner & A. S. Laurence Æ Airway management by junior doctors
. ....................................................................................................................................................................................................................
Most of the doctors (17 ⁄ 20) said they felt confident
about their ability to manage the airway prior to the
assessment. Although their opinion after assessment was
not formally sought, several commented that they had
found the experience helpful in maintaining their skills.
All 12 of the retrained doctors showed some improve-
ment during the second assessment period but they never
reached the level of the group who we considered
adequate without requiring a period of retraining.
We made no attempt to assess intubation skills. Our
intention was to assess the basic resuscitation skills of those
likely to be first on the scene in a general hospital setting,
not in an intensive area such as the operating theatre or
ITU. We were trying to provide a ‘real’ situation in relation
to equipment and help available, putting the onus on the
doctor to assess whether what they were doing was
adequate and to ask for help as they saw fit if they felt it
was not adequate. Furthermore, intubation is potentially far
more traumatic to the patient, with the opportunity for
damaged lips and teeth and possible sore throat and thus we
considered this skill inappropriate to assess in this study.
In conclusion, we have found that a group of junior
doctors were all able to ventilate the lungs with a self-
inflating resuscitation sufficiently to at least deliver basal
oxygen requirements which will sustain life for a short
time. However, those with more experience, especially
those who had attended an Advanced Life Support
course, were more effective. A brief period of training for
those poor performers improved results, but not up to the
standard of those who were adequate initially.
742
Anaesthesia, 2006, 61, pages 739–742
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2006 The Authors
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2006 The Association of Anaesthetists of Great Britain and Ireland