Combined fellowship training in head and neck anesthesia and advanced airway management

摘要

Airway management is an essential skill set for both routine anesthetic practice and life-saving measures in unexpected medical emergencies. Airway management ranges from keeping the airway patent with simple maneuvers, such as the performance of jaw lift and chin thrust, to the creation of front of the neck or infraglottic access. It is imperative for anesthesiologists to be prepared to successfully manage difficult airways when they arise, whether anticipated or unanticipated. Difficulty with airway management occurs in certain patient populations more than others, including head and neck patients. In fact, head and neck patients comprised ∼40% of the cases with airway-related complications and nearly 75% of cases where an emergent surgical airway was required in the “cannot intubate-cannot ventilate” situation in the Fourth National Audit Project (NAP4)1. The management of complex airways requires an experienced specialist. However, currently, there are only 4 airway fellowship programs or combined airway and head and neck anesthesia programs in the country. Less than 10 fellows trained in airway management/head and neck anesthesia graduate each year in the United States. These fellowship programs are 1 to 2 years in length and provide the physician-in-training an opportunity to master the advanced clinical knowledge and techniques necessary to successfully manage the most challenging clinical scenarios in airway management. These programs typically provide the fellow a structured teaching curriculum and extensive clinical exposure to a wide-range of clinical scenarios, thus enabling him/her to become a specialist in the field of airway management. An advanced airway management fellowship program typically consists of 3 components-clinical training, teaching, and research. During clinical training, the fellow primarily rotates in the operating suites in different areas, with an emphasis on difficult airway management, such as Ears, Nose and Throat (ENT) or Oromaxillofacial (OMF) cases. Airway management in head and neck surgery presents some unique challenges for anesthesiologists. Surgical procedures range from minor procedures, such as tonsillectomy, to precision laryngology cases, complex major head and neck cancer, thyroid surgery, surgery for obstructive sleep apnea, transoral robotic surgery, OMF, orthognatic surgery, facial cosmetic surgery and others. In those advanced airway management fellowship programs with an emphasis on cancer care, there is often exposure to extensive pathology resulting from head and neck cancers and their treatment with radiation therapy. Along with exposure to repeat procedures in patients with a history of a difficult airway, these cases provide trainees a unique opportunity for educational advancement in airway management. Head and neck anesthesiology is a rapidly evolving subspecialty, as there have been many technological advances in head and neck surgery, including precision techniques power magnification, and proliferation of the use of automated jet ventilation and transnasal humidified rapid insufflation ventilatory exchange (THRIVE). The understanding and intraoperative management of various head and neck pathologies continue to develop through collaboration with our surgical colleagues. New airway management devices and approaches to airway risk assessment continue to advance our treatments of complex pathologies. Thus, it is very beneficial to combine fellowship training in both head and neck anesthesia and advanced airway management. Clinical training is usually the major component of these fellowship programs. During this period, the fellow will gradually increase clinical exposure and responsibility in managing complex airway cases. Working alongside anesthesiologists with subspecialty expertise and interest in airway management, the fellow has the opportunity to gain additional clinical experience in “advanced” techniques, such as awake tracheal intubation and combination in