Preparing Anesthetists to Manage Cannot Intubate/Cannot Ventilate Situations

Cannot intubate/cannot ventilate (CICV) situations during anesthesia are rare, potentially catastrophic to the patient, and difficult to predict. Widely adopted practice guidelines advocate an algorithmic approach to CICV situations in which the anesthetist: (a) recognizes the CICV situation, (b) calls for help, (c) steadily progresses through a variety of methods to ventilate the patient and secure the airway, (d) restores ventilation via an infraglottic airway if the patient cannot be safely awakened prior to becoming moribund. Despite widespread consensus that rapid progression to placement of an infraglottic airway is critical to the survival of the patient in a CICV situation, the rarity of CICV is a substantial barrier for anesthetists attempting to gain and maintain skill at placing infraglottic airways. Peer-reviewed literature reveals a number of themes relevant to training anesthetists in infraglottic airway placement. Specific training in infraglottic airway access consistently decreased the time required for anesthetists to decide to place an infraglottic airway. No one approach or method for placing an infraglottic airway was consistently faster or more successful. Model fidelity (i.e., the use of low-fidelity task trainers vs. high-fidelity simulated patients) during teaching did not affect the performance of anesthetists at placing infraglottic airways, and performance rapidly plateaued after five repetitions during teaching. Finally, skill at placing an infraglottic airway was sustained for 6 to 12 months after training. These findings have implications for how nurse anesthetists should learn and sustain the skill of infraglottic airway placement. Nurse anesthetists should undergo initial training that requires the repetitive placement of infraglottic airways, and receive sustainment training every 6 to 12 months thereafter. Although rarely used, the skill of an anesthetist in infraglottic airway placement can mean the difference between life and death for the patient in a CICV situation.