To the Editor:--Despite initiatives by individuals [1]and by the American Society of Anesthesiologists, [2]many residency programs have been slow to offer formal training in airway management. [3]Koppel and Reed highlight a number of difficulties that “thwart residents' exposure” to such training, such as limited opportunities and inexperience with various devices and techniques. [3]New Accreditation Council on Graduate Medical Education guidelines now mandate that these skills be taught.* Such training is very important, given the frequency and severity of adverse events associated with airway management. [4].

Some centers have devised innovative ways to teach airway management, [3]for example, the University of California San Diego Airway Rotation. [5]What is not clear is the anesthesia community's opinion about teaching airway management skills without first obtaining patient consent. Consent is not mentioned by Cooper and Benumof in their description of the University of California San Diego Airway Rotation. [5]Koppel and Reed do not state in their survey whether residency programs obtain consent from patients who are used for such training. [3].

The question of consent may seem like a nonissue to some. What is the difference between selecting, for teaching purposes, a Miller or a MacIntosh blade; a laryngoscope or a light wand; a fiberoptic bronchoscope or a retrograde intubation? The difference is in the degree of risk to patients when the procedure may be unnecessary to their care. When one reviews reports of the teaching of airway management skills, some centers do, [6–9]and some do not, obtain patient consent. [3,5,10–12].

We believe that, for teaching purposes, simple substitutions of laryngoscope blades or the use of devices such as laryngeal mask airways or lightwands is appropriate without patient consent. The Combitube may be an exception; although the risk of esophageal rupture is low, the consequences may be devastating. We also believe that fiberoptic intubation in the anesthetized patient presents minimal risk, may have fewer complications than direct laryngoscopy, and does not require prior consent.

Any maneuver that significantly deviates from the standard of care should be performed only after obtaining patient consent. This includes awake fiberoptic intubation and all retrograde techniques. Likewise, repeated airway manipulations with different devices on the same patient requires prior consent. [6]To reduce patient risk due to inexperience, residents should be supervised constantly during all airway manipulations performed for teaching purposes. We also believe that prior training in a simulated environment may improve patient safety further.

Our purpose in writing is not to impede the training of residents in these important skills. We ask simply whether the anesthesia community agrees that patient consent is necessary when teaching some, but not all, airway management skills. We hope this letter will stimulate a fruitful discussion.

Gregory Allen, M.D., F.R.C.P.C.; W. Bosseau Murray, M.B., MD; Simulation Development and Cognitive Science Laboratory, Department of Anesthesia, The Pennsylvania State University, PO Box 850, Hershey, Pennsylvania 17033.

*Resident Review Committee for Anesthesiology: Revisions to Program Requirements for Anesthesiology. ACGME, Chicago, June 20, 1995.

(Accepted for publication May 2, 1996.)

Benumof JL: Management of the difficult adult airway-With special emphasis on awake tracheal intubation. ANESTHESIOLOGY 1991; 71:769-78.
ASA Task Force on Management of the Difficult Airway: Practice guidelines for management of the difficult airway. ANESTHESIOLOGY 1993; 78:597-602.
Koppel JN, Reed AP: Formal instruction in difficult airway management: A survey of anesthesiology residency programs. ANESTHESIOLOGY 1995; 83:1343-6.
Caplan RA, Posner KL, Ward RJ, Cheney FW: Adverse respiratory events in anesthesia: A closed claims analysis. ANESTHESIOLOGY 1990; 72:828-33.
Cooper SD, Benumof JL: Teaching management of the airway: The UCSD Airway Rotation, Airway Management: Principles and Practice. Edited by Benumof JL. St. Louis, Mosby, 1996, pp 903-10.
Goldberg JS, Bernard AC, Marks RJ, Sladen RN: Simulation technique for difficult intubation: Teaching tool or new hazard? J Clin Anesth 1990; 2:21-6.
Schaefer HG, Marsch SCU, Keller HL, Strebel S, Anselmi L, Drewe J: Teaching fiberoptic intubation in anaesthetised patients. Anaesthesia 1994; 49:331-4.
Cole AFD, Mallon JS, Roblin SH: Resident training: Fiberoptic vs. laryngoscopic intubation (abstract). ANESTHESIOLOGY 1994; 81:A1240.
Marsch SCU, Aeschbach A, Schaefer HG: Teaching awake fiberoptic intubation in patients without specific medical indication (abstract). ANESTHESIOLOGY 1995; 83:A1014.
Wright IH, Posner KL, Kendall-Gallagher D, Cheney FW: Usage and efficacy of the fiberoptic bronchoscope in a teaching hospital (abstract). ANESTHESIOLOGY 1994; 81:A1252.
Parmet JL, Metz S, Miller F, Pharo G, Rosenberg H: Airway Awareness Week: A method of teaching alternative airway techniques (abstract). ANESTHESIOLOGY 1995; 83:A1123.
Johnson C, El-Ganzouri AR: Teaching fiberoptic laryngoscopy and intubation, Clinical Management of the Airway. Edited by Roberts JT. Philadelphia, Saunders, 1994, pp 253-60.