616-089.5-051:371.38(497.5) AIRWAY IN CROATIA 209710860

AIRWAY MANAGEMENT EDUCATION EDUKACIJA U HRVATSKOJ U OBLASTI IN CROATIA ODRŽAVANJA DISAJNOG PUTA

Branka Maldini1,2, Tatjana Goranović2,3 Branka Maldini1,2, Tatjana Goranović2,3

1Department of Anaesthesiology, Reanimatology and Intensive 1 Odeljenje Anesteziologije, reanimatologije i intenzivne terapije, Care Medicine, Sestre milosrdnice University Hospital Centre, Kliničko-bolnički centar “Sestre milosrdnice”, Zagreb, Hrvatska Zagreb, Croatia 2 Medicinski fakultet, Univerzitet u Osijeku, Hrvatska 2Faculty of Medicine, University of Osijek, Osijek, Croatia 3 Klinika za anesteziologiju, reanimatologiju i intenzivno lečenje 3 University Department of Anaesthesiology, Reanimatology and “Sveti Duh” Univerzitetska bolnica, Zagreb, Hrvatska Intensive Care Medicine, Sveti Duh University Hospital, Zagreb, Croatia

Summary. Airway management is primarily a Sažetak. Održavanje disajnog puta je u prvom redu manual skill that must be practiced continuously if it manuelna veština koja se mora kontinuirano prak- is to achieve safe clinical practice. Official education tikovati ukoliko se želi postići sigurna klinička praksa. programs for residents are often insufficient to master Propisani službeni programi edukacije specijalizanata the specific airway management skills and do not follow su često nedovoljni za savladavanje specifičnih veština the latest trends. The paper describes our experiences održavanja disajnog puta i ne slede najnovije trendove and thoughts on education of airway management in U radu se prenose naša iskustva i razmišljanja o edu- Croatia. We propose postgraduate courses as successful kaciji u oblasti disajnog puta u Hrvatskoj. Predlažemo model for continuing medical education on the topic of kurseve kao uspešan model kontinuirane edukacije airway management. održavanja disajnog puta.

Key words: airway management, education, teach- Ključne reči: održavanje disajnog puta, edukacija, ing učenje

Introduction Modern approach to airway management assumes the use of appropriate devices to maintain irway management is a medical procedure a clear airway in the hands of experienced and Athat maintains the patency of anatomical trained professionals. The constant development of structures between the lungs and the external new tools for maintaining airway and technology, environment and thus allows airflow to the alveoli, particularly videolaryngoscopy, increases the choice i.e. ventilation. Moreover controlled airway reduces available, but presents the educational challenge the risk of aspiration of gastric contents into the as well. Given that airway management means lungs. the maintaining of the key vital function, which Airway management is primarily the subject of directly affects the safety of patients, it is important interest and training in anaesthesiology, intensive to ensure the consistent quality of the procedure. medicine, , reanimatology and In addition, it is known that a differential providing . approach to maintain the airway reduces the

Address: Branka Maldini, Sestre milosrdnice Univerzitetsko-bolnički centar, Vinogradska cesta 29, 10000 Zagreb, Hrvatska tel: 00385 99 3787 416, e-mail: [email protected] 286 SJAIT 2014/5-6 patients’ mortality and morbidity1. Therefore, to the maintenance of airway only within parts nowadays it is recommended to maintain the airway of reanimatology and selected chapters from by using the standard methods that are adapted to emergency medicine, according to which the different groups of staff and patients while being trainee must: consistent with current guidelines and algorithms • Perform endotracheal intubation (adults): which require continuous medical education of 40 procedures the staff1. Helsinki Declaration on patient safety • Perform endotracheal intubation (children in anaesthesiology from 2010 promotes not only under 5 years of age): 10 procedures the standards of safe anaesthesia practice, which • Use the manual ventilation and mechanical include the airway management , but also notes ventilation in emergency patients (adults): 40 that “education has a key role in improving patient procedures safety” 2,3. • Use the manual ventilation and mechanical ventilation in emergency patients (children aged Organisation of airway management under 5 years): 10 procedures education in Croatia • Perform crycoidectomy or percutaneous tracheostomy: 5 procedures. Obligation of mastering airway management In parts of the program of general and special techniques is described in the official program anaesthesia it is stated that the trainee must perform for physician trainees and programs for different a certain number of anaesthesia, but it does not specific specializations. specify the method of maintaining the airway. According to the program for trainee doctors In 2012 the new specialty of Emergency Medicine in Croatia (National Gazette 114/ 13)4 whose (National Gazette 100 /2011)5 was introduced internship lasts for five months it is necessary officially in Croatia. Emergency medicine trainees to acquire the following competences in airway spend part of their training at anaesthesiology management: departments where they have a chance of mastering a) The basic clinical procedures - airway - 2 the airway management’s techniques in real procedures situations. b) Program in emergency medicine (outpatient) During their round at anaesthetic department, - Cabinet skills (5 days) - maintaining a patent emergency medicine trainee should acquire the airway , artificial breathing and administration of following competencies with the designation oxygen (casting head with raising the lower jaw - levels in parentheses (1- the trainee has mastered 5 procedures , pushing the lower jaw forward - 5 the topic area at the basic level and needs help to procedures, lateral position -5 procedures, setting work and solve the problem of thematic areas; 2- – 5 procedures, setting the trainee has partially mastered the topic area - 5 procedures, suction and with partial supervision is able to work and of the airways - 5 procedures, management of a solve problems of thematic areas; 3- the trainee has foreign body in the airways - 5 procedures, the use fully mastered the topic area, knows the relevant of oxygen through a nasal catheter and a mask with literature and is able to work independently and a reservoir - 5 procedures, the method of artificial solve problems of thematic areas): respiration “ mouth -to-mouth “ and “ mouth-to- • Demonstrate the skill ventilation adults nose “ - 5 procedures, using CPR pocket mask - 5 with bag and mask (3) procedures , bag- mask ventilation for one person • Demonstrate the skill of orotracheal (10 procedures , bag- mask ventilation for two intubation adults (3) persons ( 10 procedures ), endotracheal intubation • Demonstrate the skill nasotracheal - 20 procedures , the use of laryngeal masks - 10 intubation adults (3) procedures, the use of the I- gel mask – 5 procedures. • Demonstrate the skill of laryngeal mask Training for the specialty of anaesthesiology placement in adults and children(3) and intensive care medicine in Croatia (National • Demonstrate the skill of performing Gazette 100/2011)5, which lasts for five years, crycoidectomy (3) includes a defined number of procedures relating During their round at out hospital emergency AIRWAY IN CROATIA 287 medicine, emergency medicine trainee must acquire procedures to reach the required competency. At the following competencies with the designation the moment of writing this article, we still have no levels in parentheses(1- the trainee has mastered emergency medicine specialists who finished their the topic area at the basic level and needs help to training according to this program so we can not work and solve the problem of thematic areas; 2- give any feedback on how well they manage airway the trainee has partially mastered the topic area in their daily routine. and with partial supervision is able to work and Trainees in neurology should perform 20 solve problems of thematic areas; 3- the trainee has intubations during their program of training fully mastered the topic area, knows the relevant which last for 5 years5. Trainees in general internal literature and is able to work independently and medicine should perform 10 direct laryngoscope solve problems of thematic areas): intubations5. • Demonstrate the airway management if The above described training programs do partially and completely obstructed with foreign no specify the details about the form, order and body (3) method of evaluation of airway management • Demonstrate the skill of opening and education. Supervisors confirm that the trainee has maintaining a patent airway - manual method , mastered a defined part of the program by signing placing of oro- and nasopharyngeal airway (3) the evaluation form of trainee’s competences. • Apply suction apparatus (3) • Demonstrate the skill of ventilation with Activites of Croatian Society of Difficult bag and mask in adults and children (3) Airway Management • Demonstrate the skill ventilation with bag and mask in newborns (3) Till 2011 there had been no organized form • Demonstrate the skills of endotracheal of continuous training of airway management intubation out hospital (3) in Croatia except the official program of • Demonstrate the skill of placing laryngeal anaesthesiology training, which limited the mask in adults and children ( 3 ) possibility of maintaining knowledge and skills • Demonstrate the skill of crycoidectomy (3) for the specialists who had finished their training. During their round at otolaryngology Education was sporadic and partly realized through department, emergency medicine trainee must individual educations abroad, visits to expensive acquire the following competencies with the tag workshops and conferences, and partly through the level in parentheses (1- the trainee has mastered presentation of new industrial products. the topic area at the basic level and needs help to Considering all these circumstances, in work and solve the problem of thematic areas; 2- 2011 it was established as part of the Croatian the trainee has partially mastered the topic area Medical Association, Croatian Society of Difficult and with partial supervision is able to work and Airway Management. The Society organizes solve problems of thematic areas; 3- the trainee has three postgraduate courses of continuing medical fully mastered the topic area, knows the relevant education on the topic of airway management: literature and is able to work independently and 1. “The latest insights , skills and techniques solve problems of thematic areas): to establish airway “ ; • Demonstrate the skill of performing direct, “Fiberoptic intubation in airway management indirect laryngoscopy (2) “ ;”Airway management in outpatient facilities.” • Demonstrate knowledge of the indications, The courses are held once a year, however, if there contraindications and complications of the surgical is interest for particular course, it can be repeat technique of opening the airway (3) within a year. Courses “The latest insights, skills • Demonstrate the skill of performing and techniques of establishing an airway” and crycoidectomy (3) “Fiberoptic intubation in airway management” have • Demonstrate the skill of airway management been held from 2011. This year they have been held in patients with facial (3) the fourth in a row. The course “Management of the In the specialty program of emergency medicine airway in outpatient“ is organized in collaboration there has not been specified the number of required with the Department of Emergency Medicine in 288 SJAIT 2014/5-6 Zagreb in 2013 for the first time. However till now, airway tools such as videooptic laryngoscopy. because of the great interest, it has been held third Another problem is the quality of education times. The courses have been supported by academic airway that is not specifically mentioned in the institutions: Faculty of Medicine in Zagreb and general definition of the specialization programs. Osijek and Sestre milosrdnice University Hospital We believe that specialized courses with narrowly Centre. Participants are residents and specialists defined airway topics better contribute to this in anaesthesiology, emergency medicine, intensive quality aspect. Official training programs that care medicine, neurology and doctors employed in come in the form of official gazettes, which have emergency medical care. Through workshops and long procedure of adoption and acceptance, are practical demonstrations participants are taught too sluggish and inert. On contrary, programs of basic and advanced knowledge and skills helped to postgraduate courses are more flexible. During maintain the airway on the model, and then after a postgraduate courses it is much faster and easier mastery of technique also used in operating rooms. to transfer information, and their programs are Participants are encouraged to apply their newly more prone to change. Furthermore, feedback acquired knowledge and skills as soon as possible you get from the evaluation of the quality of the and as often as possible upon their return to their course, which takes place at the end of each course, own site in their home hospitals. gives possibility to redesign and improve next course. From our experience we can recommend Discussion postgraduate courses as a form of training to master the skills of maintaining the airway, and this Airway management is primarily a manual skill is evidenced by our students whose interest does that must be practiced continuously if it is to achieve not wane. safe clinical practice 6,7. Official education programs should contain a minimum of procedures that Conclusion ensure self-mastery. The essence of official programs is the assurance of comparable knowledge. In this In this article, we wanted to share our experiences way mastering certain number of airway techniques and thoughts on education airway in Croatia. procedures becomes obligation for everybody. We hope that our example will be an incentive to This is completely opposite from romantic view of all stakeholders, especially our colleagues from some (we would add archaic view) who still think the region, to approach to airway education that mastering skills in medicine is an individual management systematically and to contribute with expression of enthusiasm. their own new solutions. Currently available written training programs in Croatia 5 are, in our opinion, insufficient References in quantitative specification of certain airway procedures. Literature data indicate that a certain 1. Dieck T, Koppert W. Helsinki Declaration on Patient number of repetitions are required for mastering Safety in Anaesthesiology--part 9: Recommendations for skills in airway management. The literature clinical airway management organisation. Anasthesiol Intensivmed Notfallmed Schmerzther 2013;48:600-7. cites the need for 30 procedures for mastering 2. Rall M, van Gessel E, Staender S. Education, teaching 8 9 direct laryngoscopy ; 5 for opticlaryngoscopy ; & training in patient safety. Best Pract Res Clin Anaesthesiol 20 for intubation with Bonfils fiberscope10; 10 2011;25:251-62. for fiberoptic intubation11. Fortunately clinical 3. Mellin-Olsen J, Staender S, Whitaker DK, Smith practice, at least during training in anesthesiology, AF The Helsinki Declaration on Patient Safety in assures more than enough airway procedures, Anaesthesiology Eur J Anaesthesiol 2010 ;27:592-7. 4. Pravilnik o pripravničkom stažu doktora medicine. although unspecified in the official program, to be Narodne novine. 2013; No. 114. Available at: taught and leant. However, that is not the case for http://narodne-novine.nn.hr/clanci/ other specializations or training programs. So we sluzbeni/2013_09_114_2489.html (Accessed: 8 July 2014) think that all existing programs should be reviewed 5. Pravilnik o specijalističkom usavršavanju doktora from the point of increasing the number of airway medicine. Narodne novine. 2011, No. 100. Available at: procedures, particulary procedures with new http://narodne-novine.nn.hr/clanci/ AIRWAY IN CROATIA 289 sluzbeni/2011_09_100_2057.html (Accessed: 8 July 2014) 6. Deakin CD, King P, Thompson F. Prehospital advanced airway management by ambulance technicians and paramedics:is clinical practice sufficient to maintain skills? Emerg Med J 2009;26:888-91. 7. Raatiniemi L, Länkimäki S, Martikainen M. Pre-hospital airway management by non-physicians in Northern Finland -- across-sectional survey. Acta Anaesthesiol Scand 2013;57:654-9. 8. Toda J, Toda AA, Arakawa J.Learning curve for paramedic endotracheal intubation and complications. Int J Emerg Med. 2013;6:38. 9. Savoldelli GL, Schiffer E, Abegg C, Baeriswyl V, Clergue F, Waeber JL. Learning curves of the Glidescope, the McGrath and the laryngoscopes: amanikin study. Eur J Anaesthesiol 2009 ;26:554-8. 10. Falcetta S, Pecora L, Orsetti G, Gentili P, Rossi A, Gabbanelli V et al.The Bonfils fiberscope: a clinical evaluation of its learning curve and efficacy in difficult airway management. Minerva Anestesiol 2012;78:176-84. 11. Johnson C, Roberts JT. Clinical competence in the performance of fiberoptic laryngoscopy and endotracheal intubation: a study of resident instruction. J Clin Anesth 1989;1:344-9.