Training in the management of pediatric airway cases has been limited by the number of cases and by the involved risks to the child. Simulation is an alternative and accessible means to practice that complex psychomotor task in a safe and reproducible environment. A high-fidelity baby mannequin provides an acceptable airway anatomic resemblance combined with measurable respiratory and cardiovascular parameters, allowing practice to be interactive and challenging. The availability of simulation laboratories within hospitals and the development of pathology-inspired accessories for the mannequins will determine the rate of adherence of ENT departments to this evolving field of simulation-based education.
Key points
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Simulation is a powerful educational mean already integrated into the curriculum of pediatric, emergency medicine, and anesthesiology programs. The recognition of its value in ENT programs is rising.
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The use of a high-fidelity baby mannequin provides real-time measurable respiratory and cardiovascular responses to the trainee’s actions, as well as airway anatomic resemblance sufficient for endoscopy.
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A joint ENT-anesthesiology team can use laryngo-bronchoscopy equipment and a ventilator to create an OR environment and practice the management of genuine cases in the SimLab.
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Simulation scripts can be adapted to match the level of the trainee: from a junior resident learning the basic psychomotor skills, to an ENT specialist desiring to maintain his or her competence in handling complex pediatric airway cases.
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The more SimLabs are created within hospitals, the more medical teams will be encouraged to participate in simulation-based training and further develop it.
Introduction
The successful management of a pediatric airway case in the operating room (OR) relies on many qualities of intervening team members. The ear, nose, and throat (ENT) specialist should have medical knowledge and the ability to grasp the clinical picture, psychomotor dexterity for the manipulation of the instruments, and familiarity with the assembly of the equipment, as well as teamworking and leadership aptitudes. The anesthesiologist has to deal with a nonsecured and often problematic airway that is being manipulated. The nurse can be required to quickly assemble and provide composite instruments. Acquiring that expertise during residency has so far been limited by the paucity and irregularity of cases, as well as by the fragility of the child’s airway, forcing the senior ENT to take over when ventilation is compromised. Similarly, maintaining competence is not always trivial for specialists who work predominantly in the adult milieu, and have to deal with pediatric emergencies occasionally. Hence, the need for an alternative teaching and practicing method is obvious.
Simulation first appeared in the 1920s in aeronautics and quickly became an essential part of learning to fly. In medicine, where the life of some also depends on the ability of others and in situ practice bares risks, the first simulation mannequin, named Resusci Annie, was introduced in the 1960s. Emergency medicine, and later anesthesiology, greatly adopted and developed the mannequin, integrating it into the curriculum of pregraduate and postgraduate years. These disciplines also led the way in research, including an ongoing effort to validate the benefits of simulation and develop sophisticated teaching methods, as well as regularly publishing comprehensive case scenarios in the leading literature. In recent years, the importance of simulation in medical education is being recognized by many additional specialties as providing interactive and safe training conditions, and a variety of dedicated mannequins and accessories have become available.
Simulation in pediatric ENT
Some ENT centers have joined the progress, focusing mainly on the teaching of anatomy and surgical technique with the use of simulators for temporal bone dissection, flexible bronchoscopy, and endoscopic sinus surgery. In some centers, simulation mannequins were used to teach crisis resource management, generating great enthusiasm among the trained residents. Still, the adhesion rate has only lately started to rise in ENT, as the spread of simulation-based education depends on, among other things, the availability of simulation laboratories. In particular, pure pediatric simulation centers are rare, and pediatric training is generally done in university or adult hospital-affiliated facilities.
The difficulties in teaching pediatric airway endoscopy, which involves high-risk and often low-frequency cases, have brought up the necessity of using an artificial environment to practice technique and case management.
The Simulation Laboratory (SimLab)
The practice of bronchoscopy and esophagoscopy and exercising foreign body (FB) retrieval was initially described by Deutsch and colleagues in 2007, on a high-fidelity, computerized baby mannequin, originally designed for training of emergency medicine cases. As the mannequin’s realistic anatomy allowed the performance of endoscopy, it has started assuming a new promising role in ENT training. Studies evaluating this tool have since started to appear, showing improved performance after training and a contribution to ENT residents’ confidence when facing situations originally encountered in simulation.
Practice in the SimLab typically involves a homogeneous group of teachers and trainees. Therefore, when simulating a case, an ENT resident or a simulation assistant is usually playing the role of the other team members, as the anesthetist, the emergency physician, or the nurse, which limits the credibility of the resulting situations.
In Situ Simulation in the Operating Room
That difficulty was bypassed by Volk and colleagues, who developed an in situ medical course taking place in the actual OR and the intensive care unit (ICU) and involving ENTs, anesthesiologists, and nurses practicing crisis management with a SimMan (Laerdal Medical, Stavanger, Norway) high-fidelity mannequin. The ensuing improved realism and team dynamics brought about an instructive experience for the trainees and exposed systemic problems within the hospital environment itself.
Reproducing the OR in the SimLab
It is possible to use the same principle of multidisciplinary team training, but this time to practice pediatric airway endoscopy and airway management on a high-fidelity baby mannequin. Hence, by exporting both OR settings and team to the SimLab, authentic OR scenarios can be executed.
In this article, we describe the technical process of setting up the pediatric airway simulation, demonstrating application of an OR scenario in the laboratory, and discussing the immediate and potential benefits, as well as the limitations of such a simulation.
Introduction
The successful management of a pediatric airway case in the operating room (OR) relies on many qualities of intervening team members. The ear, nose, and throat (ENT) specialist should have medical knowledge and the ability to grasp the clinical picture, psychomotor dexterity for the manipulation of the instruments, and familiarity with the assembly of the equipment, as well as teamworking and leadership aptitudes. The anesthesiologist has to deal with a nonsecured and often problematic airway that is being manipulated. The nurse can be required to quickly assemble and provide composite instruments. Acquiring that expertise during residency has so far been limited by the paucity and irregularity of cases, as well as by the fragility of the child’s airway, forcing the senior ENT to take over when ventilation is compromised. Similarly, maintaining competence is not always trivial for specialists who work predominantly in the adult milieu, and have to deal with pediatric emergencies occasionally. Hence, the need for an alternative teaching and practicing method is obvious.
Simulation first appeared in the 1920s in aeronautics and quickly became an essential part of learning to fly. In medicine, where the life of some also depends on the ability of others and in situ practice bares risks, the first simulation mannequin, named Resusci Annie, was introduced in the 1960s. Emergency medicine, and later anesthesiology, greatly adopted and developed the mannequin, integrating it into the curriculum of pregraduate and postgraduate years. These disciplines also led the way in research, including an ongoing effort to validate the benefits of simulation and develop sophisticated teaching methods, as well as regularly publishing comprehensive case scenarios in the leading literature. In recent years, the importance of simulation in medical education is being recognized by many additional specialties as providing interactive and safe training conditions, and a variety of dedicated mannequins and accessories have become available.
Simulation in pediatric ENT
Some ENT centers have joined the progress, focusing mainly on the teaching of anatomy and surgical technique with the use of simulators for temporal bone dissection, flexible bronchoscopy, and endoscopic sinus surgery. In some centers, simulation mannequins were used to teach crisis resource management, generating great enthusiasm among the trained residents. Still, the adhesion rate has only lately started to rise in ENT, as the spread of simulation-based education depends on, among other things, the availability of simulation laboratories. In particular, pure pediatric simulation centers are rare, and pediatric training is generally done in university or adult hospital-affiliated facilities.
The difficulties in teaching pediatric airway endoscopy, which involves high-risk and often low-frequency cases, have brought up the necessity of using an artificial environment to practice technique and case management.
The Simulation Laboratory (SimLab)
The practice of bronchoscopy and esophagoscopy and exercising foreign body (FB) retrieval was initially described by Deutsch and colleagues in 2007, on a high-fidelity, computerized baby mannequin, originally designed for training of emergency medicine cases. As the mannequin’s realistic anatomy allowed the performance of endoscopy, it has started assuming a new promising role in ENT training. Studies evaluating this tool have since started to appear, showing improved performance after training and a contribution to ENT residents’ confidence when facing situations originally encountered in simulation.
Practice in the SimLab typically involves a homogeneous group of teachers and trainees. Therefore, when simulating a case, an ENT resident or a simulation assistant is usually playing the role of the other team members, as the anesthetist, the emergency physician, or the nurse, which limits the credibility of the resulting situations.
In Situ Simulation in the Operating Room
That difficulty was bypassed by Volk and colleagues, who developed an in situ medical course taking place in the actual OR and the intensive care unit (ICU) and involving ENTs, anesthesiologists, and nurses practicing crisis management with a SimMan (Laerdal Medical, Stavanger, Norway) high-fidelity mannequin. The ensuing improved realism and team dynamics brought about an instructive experience for the trainees and exposed systemic problems within the hospital environment itself.
Reproducing the OR in the SimLab
It is possible to use the same principle of multidisciplinary team training, but this time to practice pediatric airway endoscopy and airway management on a high-fidelity baby mannequin. Hence, by exporting both OR settings and team to the SimLab, authentic OR scenarios can be executed.
In this article, we describe the technical process of setting up the pediatric airway simulation, demonstrating application of an OR scenario in the laboratory, and discussing the immediate and potential benefits, as well as the limitations of such a simulation.
Steps in creating pediatric airway simulation
Establishing the appropriate environment for training in settings that resemble those of an airway case performed in the OR requires the following:
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Using a SimLab
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Gathering the equipment
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Assembling the team
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Defining the learning objectives and case scenarios
The SimLab is ideally located within the pediatric hospital, easily accessible to both residents and staff from the different disciplines, whose schedule is by definition very busy. Alternatively, an adult simulation center can be used if adapted with proper equipment, namely a high-fidelity baby mannequin ( [CR] ).
The high-fidelity baby mannequin has the size and shape of a 10-month old baby. It is connected to a monitor and possesses basic anatomic as well as computer-controlled dynamic features, allowing the trainee to perform a physical examination and observe an immediate response to certain therapeutic maneuvers. These include a chest wall that moves according to unilateral/bilateral breathing, audible breath sounds, cardiac and vocal sounds, palpable pulses, venous access, and measurable parameters, such as O2 saturation, CO2, blood pressure, and so on. Airway wise, it has a vallecula, an epiglottis, arytenoids, and the posterior two-thirds of the vocal cords. The larynx can be shifted anteriorly to make the endotracheal intubation very difficult, and the cords can adduct to mimic a laryngospasm. Below the vocal cords, the trachea presents with a narrower ring in its proximal part that can be considered to be a grade 1 subglottic stenosis, a carina distally leading to the 2 main stem bronchi and their first subdivisions. Far from being perfect, the mannequin’s anatomy sufficiently resembles human anatomy to allow the user to recognize the anatomic location of the area he or she is manipulating.
Team
Both an ENT and anesthesiologist attending devoted to simulation-based teaching are essential for multidisciplinary credible training. Preferably, a third physician, who masters the training software can be the simulation manager, responding “on the fly” to critical actions by participants in the scenario’s branching points ( Table 1 ).
