Cardio Respiratory Monitoring —
Training activity: 6

Details

Advise a clinical colleague on the various difficult airway procedures and the equipment available for this in intensive care

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Classification of difficult airways and how these can be treated
• Difficult airway trolley contents and their uses
• Trolley checklists and protocols and a critical care scientist’s role within these
• Patient centred care and support
• Communication with patients, relatives and the clinical team

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to advising a colleague on both difficult airway procedures (e.g., rapid sequence intubation, fibreoptic intubation) and the associated equipment in the ICU setting.
• Consider how the learning outcomes apply, specifically in relation to appraising techniques and advising on appropriate respiratory techniques, effectively communicating complex procedural steps, and practicing safely by advising according to established difficult airway algorithms.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the range of difficult airway procedures and equipment you should be familiar with for advising colleagues in your unit, including specific protocols for unrecognised difficult airways.

What is your prior experience of this activity?

• Think about what you already know about different difficult airway procedures (e.g., video laryngoscopy, fibreoptic intubation, surgical airway) and the necessary equipment for each.
• Consider possible challenges you might face during the activity, such as explaining complex, sequential procedures (e.g., a failed intubation algorithm) or tailoring advice based on the urgency of the clinical situation.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if a colleague asks for advice on managing a rare complication of a difficult airway procedure, such as major bleeding during cricothyrotomy.
• Acknowledge how you feel about embarking on this training activity, particularly your confidence in discussing both difficult airway procedures and their associated equipment.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as improving your ability to clearly and concisely explain difficult airway algorithms or integrating knowledge of procedures and equipment selection for effective advice, drawing upon previous experiences.
• Identify the specific insights you hope to gain into the practical application of procedures (e.g., observing intubation) and equipment in different critical care clinical scenarios.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of airway management, procedures, or advising colleagues.
• Identify important information you need to consider before embarking on the activity, such as reviewing the local difficult airway guidelines, the indications for different procedures, and ensuring you are familiar with the location and readiness of equipment like the difficult airway trolley.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst advising a colleague on various difficult airway procedures and the associated ICU equipment?
• Are you encountering situations such as:
  • The colleague presents a highly complex clinical scenario involving multiple comorbidities (e.g., cervical spine instability) that necessitate modification of standard procedural advice (e.g., cricothyrotomy)?
  • Unexpected questions arise regarding the logistics of managing two simultaneous procedures (e.g., fibreoptic intubation and mechanical ventilation requirements)?
  • The required equipment for a specific procedure is noted to be missing or malfunctioning in the ICU environment during the advisory discussion?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to articulating procedural steps or integrating risk management into your advice?
• Consider the steps you are taking in the moment, such as:
  • Immediately seeking clarification on the exact available resources in the unit to ensure the advice is practical and feasible for the current ICU setting
  • Adapting your advice to focus solely on procedural steps within your scope of practice, while deferring management decisions to the relevant clinical team
• How are you feeling in that moment? For instance, are you finding it difficult to maintain composure while discussing high-stakes critical care procedures? Is it affecting your confidence in referencing specific ICU guidelines quickly?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully advising on procedural requirements and equipment checks from memory, ensuring adherence to safety protocols? Or are you needing support because the procedure required falls outside routine ICU protocol and necessitates consultation with the intensivist or senior anaesthetist?
• What are you learning as a result of the unexpected development? For example, are you mastering clearer communication of procedural risks? Or gaining insight into the specific interplay between difficult airway management and ICU environmental constraints?

On action

What happened?

• Begin by summarising the key steps you took when advising the clinical colleague on difficult airway procedures and available equipment in intensive care.
• Consider specific events, actions, or interactions which felt important, such as the discussion regarding the sequence of steps in a failed intubation algorithm or the comparison of different laryngoscopy techniques.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, pausing to consult the local Difficult Airway Society guidelines to verify a procedural step when the colleague raised a query.
• How did you feel during this experience, e.g., did you feel confident discussing procedural theory or overwhelmed by the need for immediate accuracy regarding complex protocols?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding advising colleagues on complex procedures and equipment within intensive care. What strengths did you demonstrate, e.g., comprehensive knowledge of the available difficult airway equipment in the ICU?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the contraindications for certain procedural steps in specific patient populations?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in clearly linking the procedure (e.g., fibreoptic intubation) to the required specific equipment?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the management of a surgical airway procedure, which is outside routine scope, and how you reacted to this.
• Acknowledge any changes in your own feelings now that you are looking back on the experience.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to reviewing the evidence base for specific difficult airway procedures like cricothyrotomy.
• What will you do differently next time you approach advising on difficult airway procedures or equipment, for instance, by proactively rehearsing the steps of the local difficult airway algorithm?
• Do you need to practise any aspect of the activity further, such as communicating complex procedural sequence effectively or key learning outcomes related to appraising techniques for respiratory function?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of participation in complex airway simulation training focusing on procedural algorithms (e.g., Failed Intubation) since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, the need to recall sequential steps for emergency front-of-neck access forced you to re-evaluate the depth of your memorisation of difficult airway protocols during your first attempt at this training activity.
• Considering what you understand about procedural safety and the sequence of difficult airway algorithms now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your advisory communication regarding difficult airway procedural options based on further learning and experiences? For example, how you proactively integrated the latest Difficult Airway Society (DAS) guidelines into your mental checklist for emergency management based on further learning.
• Has discussing the indications for fibreoptic intubation or the impact of procedural delay on patient outcomes in critical care with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior ICU consultant about a case requiring immediate surgical airway access due to failed non-surgical procedures refined your understanding of the critical role of timely procedural advice.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent advisory and observation experiences, contributed to your overall confidence and ability in clearly articulating the various difficult airway procedures and the required equipment, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated knowledge of difficult airway algorithms and associated equipment logistics now enables you to confidently appraise procedural options with a clinical colleague during an OCE assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to advising colleagues on difficult airway procedures? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or Intensivist immediately when a colleague requires guidance on managing complications during a difficult airway procedure (e.g., surgical airway complications), recognising this requires senior clinical management and intervention.
• Looking holistically at your training journey, how has this initial difficult airway procedures advisory experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to appraising techniques to maintain patient respiratory function and practicing safely? For example, how this foundational experience has supported your development in understanding the critical safety implications of high-stakes respiratory procedures.

Relevant learning outcomes

#	Outcome
# 3	Outcome Appraise techniques to maintain patient respiratory function, advising on appropriate techniques for the clinical scenario.
# 5	Outcome Communicate effectively with the patient and the multi-disciplinary team.
# 6	Outcome Practice safely, managing risk in all elements of patient care.