Confidence in airway management proficiency: a mixed methods study of intensive care specialists in Australia and New Zealand

Abstract

Objective: To explore self-confidence, and the respective facilitators and barriers, among intensive care specialists in Australia and New Zealand in relation to airway management.

Design: A mixed methods study.

Setting: 11 intensive care units across Australia and New Zealand.

Participants: 48 intensive care specialists.

Intervention: A structured online interview and the presentation of three discrete airway management clinical scenarios — routine endotracheal intubation, awake fibreoptic intubation (AFOI), and emergency front of neck access (FONA).

Main outcome measures: Graded Likert scale responses regarding confidence in airway management were analysed, and perceptions of facilitators and barriers to confidence in each select scenario were obtained as free text. A deductive thematic analysis was done iteratively on free text entry and allowed for the development of a coding framework. NVivo software used the coding framework to run coding queries and cross-tabulations for comparison of relationships between themes and participant demographic characteristics.

Results: Participants reported differing levels of confidence. Clinical experience, an anaesthetic qualification and training (including simulation) were the major facilitators to influencing confidence. Participants were more confident performing routine intubation than AFOI or FONA. Equipment, checklists or protocols, and availability of video-laryngoscopy were also identified as facilitators to confidence by most participants. Work relationships, teams and other staff availability were identified as further facilitators to confidence; lack of these factors were less commonly identified as barriers.

Conclusions: Confidence in airway management among intensive care specialists in Australia and New Zealand varies, both between specialists and depending on clinical context. Multiple facilitators to improving this exist, including additional mandatory training.

Airway management is an essential component of intensive care practice. However, recent research suggests that the current volume of practice with regards to intubation by intensive care specialists in Australia and New Zealand may be inadequate to maintain confidence and clinical proficiency.1, 2 While the Australian and New Zealand College of Anaesthetists (ANZCA) mandates ongoing airway education as part of their continuous professional development (CPD) program, the College of Intensive Care Medicine of Australia and New Zealand (CICM) does not.¹ Recent research showed that 52% of Australian intensive care specialists had not received a refresher training in airway management within the past 3 years.³ This may potentially result in an inadvertent skills gap, as skill decay is well described for resuscitation and airway management procedures and typically occurs within 6-12 months.4, 5, 6 However, most studies address novices, whereas the specific rate of skill decay for intensive care specialists' airway management is unknown. It is likely that the rate of skill decay in airway management in experts is inversely related to the previous level of expertise achieved and the total volume of practice.

Complications from failed airway management include aspiration, brain injury, cardiac arrest and death.7, 8, 9, 10 These occur more frequently when managing critically ill patients in the intensive care unit (ICU).^3,7,8,11 Considerably more airway-related complications result in death and brain damage in the ICU compared with the operating theatre or emergency department.^8,12 Not only are complication rates higher in the ICU, but the frequency of failed airways is also significantly higher.⁸ The recently published INTUBE study highlighted the significant morbidity and mortality associated with intubation in the critically ill patient, showing a 45% risk of major adverse events and a 3% risk of cardiac arrest.³

Patient, operator and situational factors contribute to airway-related complications.^3,11 In the critical care setting, many of these are unmodifiable. These include patient factors such as obesity, pregnancy and airway anatomy. Physiological derangements such as cardiorespiratory instability or impaired cerebral autoregulation further complicate airway management and are often difficult to optimise.9, 10, 12, 13 Clinician expertise is critical to the success of an intubation, possibly even more so in the intensive care environment given that prolonged attempts are associated with major morbidity.³ Factors related to insufficient training in difficult intubations have been implicated in 49-58% of cases, and good airway management in the ICU has been reported to be as low as 11%.^7,8 The United Kingdom-based 4th National Audit Project (NAP4) found that operator factors contributed in some way to adverse outcomes in 40% of cases, with further analysis suggesting these may contribute in all instances.^7,8,14 Human factors in critical care airway interventions are significant. Therefore, increased preparation, training and experience may improve outcomes in airway interventions in the ICU. Fundamental clinician factors, such as lack of expertise, may be responsive to training.

“Confidence” is a colloquial term to represent self-efficacy in a given situation, where self-efficacy means an individual’s belief in their capacity to execute behaviours necessary to achieve a level of performance.¹⁵ In turn, perceived self-efficacy can affect performance. Lack of clinician confidence is thought to affect clinician wellbeing, with excessive anxiety and stress responses impairing performance.^16,17 To our knowledge, there are no standardised measures of clinician self-confidence for invasive procedures. This mixed methods study aims to explore clinician perspectives on self-confidence, and the respective facilitators and barriers, in relation to airway management by intensive care specialists in Australia and New Zealand. Understanding these perceptions may help inform strategies to improve and maintain intensivist airway management skills, where necessary, and therefore improve patient care. Three fundamental questions are addressed:

• •What are the intensive care specialists’ perceptions of their airway management skills?
• •What do they perceive to be the barriers to these skills?
• •What do they perceive to be the facilitators to improving these skills?

Methods

Ethics approval for this study was granted from Cabrini Research Governance (Ref. 06-06-05-21).

An online structured interview was designed by a team of experts in airway management, each with Fellowships in intensive care medicine or anaesthesia and significant experience in advanced airway management education. Three scenarios (Online Appendix) were designed to assess participants’ perceptions of their airway management skills, to explore the barriers to confidence in managing specific scenarios, facilitators of confidence, and requirements to improve these skills. These scenarios presented participants with the following situations:

• •a routine endotracheal intubation in the setting of sepsis;
• •an awake fibreoptic intubation (AFOI) in the setting of angioedema; and
• •a can’t intubate can’t oxygenate (CICO) scenario, requiring progression to emergency front of neck access (FONA) with the participant’s choice of technique.

The structured interview was disseminated using a convenience sample of 11 ICUs across Australia and New Zealand, in both metropolitan and rural settings among public and private hospitals. ICU directors were contacted via email and asked to invite their specialist staff with Fellowships (completed specialty training) in intensive care medicine to complete the interview. The interview data were collected using the cloud-based software Qualtrics (Provo, UT, USA). The interview was closed after a predetermined threshold of 50 responses was reached.

The structured interview collected a combination of baseline demographic information, graded Likert scale responses regarding confidence in airway management in each clinical scenario, and perceptions of facilitators and barriers to confidence in each scenario. Open questions allowed free text entry for thematic analysis.

Five responses were initially analysed to identify common themes. A deductive analysis was done iteratively by four authors (JS, DB, JB, IU) and allowed for the development of a coding framework. Thematic saturation occurred after analysis of responses from participants. The coding framework and all 48 included interviews were entered into NVivo software version 12 (QSR International). Free text responses were analysed with the coding framework using the software. Coding queries and cross-tabulation allowed for analysis and comparison of relationships between themes and participant demographic characteristics. Results were tabulated.

Results

The baseline demographic data of participants can be seen in Table 1. Participants varied in age, number of years of practice as an intensive care specialist, and additional Fellowships.

Table 1.

Baseline demographic characteristics of the participants

Characteristics	n (%)
Total number of participants	48
Age, years
30-39	8 (17%)
40-49	24 (50%)
50-59	10 (21%)
60-69	6 (12%)
Years of practice as an intensive care specialist
≤ 5	13 (27%)
6-10	11 (23%)
> 10	24 (50%)
Additional Fellowships
None	14 (27%)
Anaesthetist (total)	16 (33%)
Anaesthetist (FANZCA)	10 (19%)
FACEM	9 (17%)
FRACP	8 (15%)
Hospital
Victoria
The Austin Hospital	3 (6%)
The Alfred Hospital	7 (15%)
Cabrini Hospital	6 (13%)
University Hospital Geelong	1 (2%)
New South Wales
Royal North Shore Hospital	10 (21%)
Wagga Wagga Base Hospital	3 (6%)
Tasmania
Launceston General Hospital, Tasmania	1 (2%)
Queensland
Noosa Hospital	4 (8%)
Western Australia
Sir Charles Gairdner Hospital	6 (13%)
New Zealand
Middlemore Hospital	2 (4%)
Wellington Hospital	5 (10%)

FACEM = Fellow of the Australasian College for Emergency Medicine; FANZCA = Fellow of the Australian and New Zealand College of Anaesthetists; FRACP = Fellow of the Royal Australian College of Physicians.

Quantitative data

The reported confidence of participants in each of the three airway scenarios is presented in Table 2. Participants were more confident performing a relatively routine emergent intubation than they were performing AFOI or FONA. In the former case, 98% of participants were at least “fairly confident”, whereas in the latter clinical cases confidence fell to 29% and 20% respectively.

Table 2.

Confidence in airway procedures

Confidence	Scenario 1: routine ETI (n, %)	Scenario 2: AFOI (n, %)	Scenario 3: emergency FONA (n, %)
Total number of participants	48	48	48
Not at all confident	0	8 (17%)	1 (2%)
Not so confident	1 (2%)	14 (29%)	8 (17%)
Somewhat confident	0	12 (25%)	29 (60%)
Fairly confident	18 (37%)	10 (21%)	9 (19%)
Extremely confident	30 (61%)	4 (8%)	1 (2%)

AFOI = awake fibreoptic intubation; ETI = endotracheal intubation; FONA = front of neck access

Multiple demographic factors determined the level of confidence in each scenario (Table 3). Participants who had more than 5 years of experience as a specialist were significantly more likely to be confident performing AFOI (P < 0.05). Participants with an additional ANZCA Fellowship (FANZCA) or other recognised anaesthetic Fellowship were significantly more confident in both the routine endotracheal intubation (P < 0.05) and AFOI scenarios (P < 0.01). Those with a FANZCA who were practising anaesthetists were significantly more confident in the AFOI compared with all other participants (P < 0.01). Participants with a Fellowship of the Royal Australian College of Physicians (FRACP) were significantly more confident in managing the emergency FONA scenario (P < 0.05).

Table 3.

Confidence among different demographic factors

Confidence	Total (n, %)	Years of practice as specialist (n, %)			FANZCA or other anaesthetic Fellowship (n, %)			FANZCA and practising anaesthetist (n, %)			FRACP (n, %)			FACEM (n, %)
		≤ 5 years	> 5 years	P	Yes	No	P	Yes	No	P	Yes	No	P	Yes	No	P
Total number of participants	48	13	35		16	32		7	41		8	40		9	39
Routine ETI				0.55			<0.05			0.09			0.35			0.35
Not at all confident	0	0	0		0	0		0	0		0	0		0	0
Not so confident	1 (2%)	0	1 (3%)		0	1 (3%)		0	1 (2%)		0	1 (3%)		1 (3%)	0
Somewhat confident	0	0	0		0	0		0	0		0	0		0	0
Fairly confident	18 (37%)	6 (46%)	11 (31 %)		2 (13%)	15 (47%)		0	17 (42%)		4 (50%)	13 (33%)		12 (31 %)	5 (56%)
Extremely confident	30 (61%)	7 (54%)	23 (66%)		14 (88%)	16 (50%)		7 (100%)	23 (56%)		4 (50%)	26 (65%)		26 (67%)	4 (44%)
AFOI				<0.05			<0.01			<0.01			0.16			0.80
Not at all confident	8 (17%)	1 (8%)	7 (20%)		0	8 (25%)		0	8 (19.5%)		2 (25%)	6 (15%)		6 (15%)	2 (22%)
Not so confident	14 (29%)	8 (62%)	6 (17%)		1 (6%)	13 (41 %)		0	14 (34%)		3 (38%)	11 (28%)		12 (31 %)	2 (22%)
Somewhat confident	12 (25%)	2 (15%)	10 (29%)		6 (38%)	6 (19%)		1 (14%)	11 (27%)		0	12 (30%)		9 (23%)	3 (33%)
Fairly confident	10 (21%)	2 (15%)	9 (23%)		6 (38%)	4 (13%)		3 (43%)	7 (17%)		1 (13%)	9 (23%)		8 (21 %)	2 (22%)
Extremely confident	4 (8%)	0	4 (11 %)		3 (19%)	1 (3%)		3 (43%)	1 (2%)		2 (25%)	2 (5%)		4 (10%)	0
FONA				0.86			0.47			0.14			<0.05			0.28
Not at all confident	1 (2%)	0	1 (3%)		1 (6%)	0		1(14%)	0		0	1 (3%)		1(3%)	0
Not so confident	8 (17%)	3 (23%)	5 (14%)		2 (13%)	6 (19%)		1 (14.3%)	7 (17%)		3 (38%)	5 (13%)		7 (18%)	1 (11 %)
Somewhat confident	29 (60%)	8 (62%)	21 (60%)		11 (69%)	18 (56%)		3 (43%)	26 (63%)		2 (25%)	27 (68%)		25 (64%)	4 (44%)
Fairly confident	9 (19%)	2( 5.4%)	7 (20%)		2 (12.5%)	7 (22%)		2 (29%)	7 (17%)		2 (25%)	7 (18%)		5 (13%)	4 (44%)
Extremely confident	1 (2%)	0	1 (3%)		0	1 (3%)		0	1 (2%)		1 (13%)	0		1 (3%)	0

AFOI = awake fibreoptic intubation, ETI = endotracheal intubation, FANZCA = Fellow of the Australian and New Zealand College of = front of neck Anaesthetists, FONA access, FRACP = Fellow of the Royal Australian College of Physicians.

Facilitators of confidence

Clinical experience was the most common facilitator of confidence in managing the presented scenarios. Of all participants, 94% (n = 45) referenced being confident in managing the scenario due to extensive clinical practice. In addition, prior successful management of a similar scenario conferred confidence with managing the presented scenario. Despite a lack of clinical experience in some cases, participants frequently referred to their participation in training, including training in anaesthetics and as a registrar, attendance at airway courses and participation in simulation as facilitating their confidence in airway management. Such training also included individual practice, self-study and familiarising themselves with protocols and algorithms related to specific scenarios.

Training was identified as a facilitator of confidence by 73% of participants, whereas simulation and teaching were identified by 38% and 17% of participants respectively (Table 4). Participants identified their specialist training program, including the 12 months of anaesthesia time required in Australian and New Zealand intensive care training, as being important for their confidence. Participants also described simulation training, including animal models, as being important for their confidence, although others noted the limitation of these training tools. Most participants said that more training (69%), simulation experience (58%), or clinical practice (60%) would further improve their confidence (Table 4). Participants without a Fellowship in anaesthetics were more likely to discuss simulation. Several participants explained that they maintained clinical experience by attending theatre, either as an anaesthetist or as part of CPD (Table 5).

Table 4.

Proportion of participants referencing each code

Codes	n (%)
Total number of participants	48
1.0 Facilitators of confidence due to individual skills
1.1 Clinical experience	45 (94%)
1.2 Similar past experiences	30 (63%)
1.3 Training	35 (73%)
1.4 Simulation	18 (38%)
1.5 Teaching	8 (17%)
1.6 Anticipation	12 (25%)
1.7 Clinical skills	17 (35%)
2.0 Facilitators of confidence due to perceptions of organisational support
2.1 Access to equipment	18 (38%)
2.2 Checklists and protocols	10 (21%)
3.0 Facilitators of confidence due to personnel support
3.1 Work relationships	6 (13%)
3.2 Team competence	17 (35%)
3.3 Other staff availability	12 (25%)
4.0 Barriers to confidence due to individual skills
4.1 Lack of clinical experience	40 (83%)
4.1.2 More experienced clinician available	26 (54%)
4.1.3 Lack of recency	15 (31%)
4.2 Lack of training	17 (35%)
4.3 Unanticipated complications	9 (19%)
4.4 Anticipated complications	21 (44%)
4.5 Technically challenging scenario	22 (46%)
4.6 Mentality	11 (23%)
5.0 Barriers to confidence due to organisational support
5.1 Lack of access to equipment	4 (8%)
6.0 Barriers to confidence due to personnel support
6.1 Team competence	4 (8%)
6.2 Availability of personnel	9 (19%)
7.0 Improving confidence
7.1 Clinical experience	29 (60%)
7.2 Other staff input	16 (33%)
7.3 Protocols	2 (4%)
7.4 Simulation	28 (58%)
7.5 Training	33 (69%)
7.6 Anticipation	1 (2%)

Table 5.

Facilitators of confidence

Facilitator to confidence	Illustrative participant quotations
Clinical experience	•“I am careful to maintain skills, either through direct experience or simulation, in order to be across approaches to airway management and the practical and non-technical skills around airway management.” (Participant 8) •“My volume of practice of airway management, including current fibreoptic intubation experience in theatre and expert training.” (Participant 12) •“I think as a registrar I was fortunate to have excellent mentors and be able to perform many more tracheostomies than registrars in larger centres which has given me confidence that if it all goes wrong I can access front of neck.” (Participant 17)
Similar past experiences	•“Personal experience of 2 successful emergency cricothyroidotomies previously.” (Participant 10) •“No markers of difficult airway. I've intubated a lot of patients in this scenario.” (Participant 19) •“Have done it many times and have never failed yet.” (Participant 33) •“I have performed 100s of tracheostomies and I am comfortable with the steps that are required to urgently obtain FONA.” (Participant 45)
Training	•“I attend theatre 1-2 times per year to skill up on VL and SGA use and receive consultant peer review feedback on technique. This infuses me with confidence. Having an airway expert tell me I'm ok/safe is something I think about before I intubate in ICU.” (Participant 2) •“A solid year of anaesthetics with good mentors allowing me to use a variety of airway equipment for difficult airway on patients with normal airways so if encountered I would know how to use [them].” (Participant 17) •“I've been drilled in this procedure for many years, and have performed on animals in training courses. I continue to rehearse both imaginatively and on props, and review theory regularly.” (Participant 21) •“Have mentally rehearsed the procedure. Have performed the procedure on models blindfolded with distracting music to partially simulate the real stress of the situation.” (Participant 28)
Access to equipment	•“Availability of C-MAC [Karl Storz] as our standard intubation kit — we always use this regardless of anticipated airway grade. Confidence in our backup devices (ie, i-gel [Intersurgical] LMA).” (Participant 17) •“We have an appropriately equipped airway trolley with all required elements on it (including Berman airways [Flexicare], topical agents, etc).” (Participant 27) •“[Percutaneous cricothyroidotomy] kit available in difficult airway trolley. Know the kit — have used in practice scenarios and have done a couple of [percutaneous cricothyroidotomies].” (Participant 35)
Team competence	•“I have excellent trainees with good levels of experience. Teaching airway skills maintains recency of practice.” (Participant 6) •“We have experienced nursing staff and registrar staff who are often overseas trained anaesthetists.” (Participant 17) •“Well trained staff who are familiar with our ‘Vortex-based’ CICO algorithm⁎.” (Participant 27)

CICO = can’t intubate can’t oxygenate; ICU = intensive care unit; FONA = front of neck access; LMA = laryngeal mask airway; SGA = supraglottic airway; VL = video laryngoscope.

^⁎CICO rescue: http://vortexapproach.org/cicorescue

Barriers to confidence

The most frequently referenced barriers to confidence in the airway scenarios were a lack of clinical experience, the availability of a more experienced clinician, anticipation of complications and the technically challenging nature of the scenario presented (Table 6). Participants with an additional Fellowship in anaesthetics were less likely to list a lack of clinical experience and a lack of training as barriers to confidence in airway management. Participants without an anaesthetic Fellowship were more likely to lack confidence due to the availability of a more experienced clinician (65%, n = 20) than fellow anaesthetists (35%, n = 6).

Table 6.

Barriers to confidence

Barrier to confidence	Illustrative participant quotations
Lack of clinical experience	•“This is not a commonly done procedure. I’ve never previously done an emergency FONA.” (Participant 12) •“This is a difficult intubation. I never do fibreoptics and this is a skill that needs to be maintained and practiced regularly.” (Participant 19) •“Never have done a real one (thank goodness). It is always different to how you’d imagine so there is a degree of uncertainty which makes me nervous.” (Participant 21) •“Lack of experience managing the awake patient in this process. Lack of experience in managing the ABNORMAL airway with [awake fibreoptic intubation] (that is, I have extensively practised [fibreoptic intubation] on manikins – but never manikins with a crowded larynx or narrowed glottic opening!).” (Participant 27) •“I have never had to perform an emergency cricothyroidotomy so do not have high levels of confidence in performing this.” (Participant 39)
Availability of more experienced clinician	•“Knowing that I am not the most expert person in the building at airway management. This will mean should first pass be unsuccessful then it will cross my mind as to whether I call for help.” (Participant 2) •“I have not performed [fibreoptic intubation] since [I was] a registrar and even then only once. This was years ago now; I think most anaesthetists would have had much more recent experience and I would at least want someone with me if available to assist.” (Participant 17) •“The most experienced person available should attempt this difficult and emergent scenario. If I am the most experienced person available, I will take responsibility; if not, I will defer to whomever is.” (Participant 41) •“This a specialist procedure that I think even if I did SIM and occasional practice in theatre that I would not be as well placed as an anaesthetist.” (Participant 48)
Lack of recency	•“The only factor would be that as consultants we do more supervising and less hands on for routine intubations to give registrars experience, which means we are not intubating as often as when we were registrars.” (Participant 17) •“Certainly as I get older and the number of emergency [intubations] I perform or directly supervise decreases I am constantly aware of potential de-skilling.” (Participant 30) •“No intubations in [the] last year. Minimal experience with video laryngoscopy which seems to [be] the go-to these days. A few situations around 4 years [ago] where I struggled with an intubation.” (Participant 48)
Technically challenging	•“I recognise that this could be a physiologically and situationally difficult airway, in a shocked patient and in a non-theatre environment.” (Participant 39) •“This is a difficult airway scenario, one has to be prepared for all scenarios including [a] surgical airway.” (Participant 43)
Anticipated complications	•“Large BMI predicts [that] this is harder than most surgical airways. Critically hypoxic makes timely procedure more stressful.” (Participant 6) •“Practice on model never the same as real thing and this patient [is] hypoxic and likely to arrest … time-critical procedure with high risk of failure and/or morbidity … No-one should feel confident in this situation!” (Participant 19) •Regarding Scenario 1 routine endotracheal intubation: “Sepsis and LVF — potential for cardiac collapse with induction.” (Participant 35)
Mentality	•“I am fortunate to work in environments where similar levels of support are available day and night, but [I] am mindful that cognitive and executive function decays overnight.” (Participant 8) •“It is always different to how you’d imagine so there sssis a degree of uncertainty which makes me nervous.” (Participant 21) •“One day I will be caught out by overconfidence.” (Participant 23)

BMI = body mass index; LVF = left ventricular failure; SIM = intubation simulation.

Discussion

This mixed methods study has identified several important factors that determine confidence in airway management among intensive care specialists in Australian and New Zealand. Participants from a variety of metropolitan and rural centres across both countries, including those with and without additional specialist qualifications, reported varying levels of confidence in different clinical scenarios. Clinical experience was a major factor influencing confidence, either positively or negatively. Participants were more confident performing the more common procedure (routine emergent intubation) than they were performing less common AFOI or FONA. AFOI and FONA are infrequently performed in the ICU in Australia and New Zealand, and are arguably more technically challenging than conventional intubation, either of which may explain the difference. Having a qualification as an anaesthetist was associated with increased confidence in the routine endotracheal intubation and AFOI scenarios; however, there was no difference between practising and non-practising anaesthetists. This suggests that it is anaesthesia specialty training, rather than post-qualification experience, that these specialists consider more valuable. While intensive care training requires 12 months of clinical anaesthesia time, anaesthesia training requires a minimum of 4.4 years.¹⁸ This additional time appears to instil confidence in dual-qualified specialists, an observation consistent with a higher level of initial experience or skill being protective against skill decay.

Participants identified their specialist training program, including the 12 months of anaesthesia time required during intensive care Fellowship training, as being most important for their confidence. Participants also described simulation training, including animal models, as being important for their confidence, although others noted the limitation of these training tools. Most participants said that more training, simulation experience or clinical practice would further improve their confidence. Training events and courses, including simulation training, are ubiquitous in airway management CPD.¹⁹ A short CICO course is the only mandatory airway component of the ANZCA CPD program. While these CPD activities certainly have value, they are not the only important element identified by participants in this study. Participants frequently stated that during airway management they would consider asking for help (either before the procedure or if complications ensued) from a more experienced clinician, such as an anaesthetist. Some Australian hospitals have on-site specialist anaesthetists after hours, but the majority do not. For most intensive care specialists, another senior clinician is not always readily available. This is especially true for time-critical emergencies such as a CICO event. Training and CPD programs must ensure intensive care specialists have the required skills to personally manage these time-critical airway emergencies.

Equipment, checklists or protocols were also identified as facilitators to confidence in airway management by most participants in at least one scenario. Availability of video laryngoscopes, as well as AFOI and FONA equipment, further improved the confidence of some participants. Video laryngoscopes are an increasingly available tool in the ICU, particularly as they have become standard of care for intubations in patients with coronavirus disease of care for intubations in patients with coronavirus disease 2019 (COVID-19).²⁰ Work relationships, teams and other staff availability were identified as further facilitators to confidence; these factors (or lack thereof) were less commonly identified as barriers. Having shared mental models, and having trainees with extensive experience, were both identified as improving confidence. This highlights the known role for team-based multidisciplinary training in airway management CPD — an activity that ANZCA explicitly endorses as part of their CPD program. This should be explored further in CICM training, given the known benefits of team training in the ICU.²¹

The findings of this study should be viewed in the context of other studies that have shown modest volumes of airway practice among intensive care specialists in Australia and New Zealand.^1,2 Maintaining clinical experience outside that routinely seen in daily practice is a challenge for many specialists, often requiring the use of valuable non-clinical time or attending work in unpaid hours. Some hospitals do have systems in place that allow intensive care specialists to attend operating theatres to obtain airway-specific experience.²² This may be resource intensive, but it is possible that this real-world hands-on experience is as valuable as, or more valuable than, conventional courses. Any training undertaken by intensive care specialists to improve airway proficiency should emphasise that intubation in the intensive care setting is particularly difficult and associated with more complications.¹¹ Short “booster training” sessions, which have been shown in similar clinical areas to have good effect on expertise, would likely also be particularly beneficial.^23,24 Finally, although AFOI has been considered a core airway skill for anaesthetists, even many anaesthetists lack opportunity to practise their skills, and discomfort with the procedure may lead to it being overlooked as an option.²⁵ The challenge in obtaining training and experience with awake intubation is even greater for intensive care specialists.

One limitation of this study is the convenience sampling used. A recent Australian and New Zealand Intensive Care Society (ANZICS) report on Australian ICU capacity identified that of 2228 total ICU beds in Australia, 799 (36%) were in tertiary hospitals, 291 (13%) in regional/rural locations, and 725 (33%) in private hospitals.²⁶ In 2019-20, ANZICS reported that almost 50% of the total full-time equivalent senior medical staff positions in Australian ICUs were in tertiary locations, while less than 15% were in each of regional and private locations.²⁷ Our sample may therefore slightly over-represent specialists from regional (23%) and tertiary (64%) hospitals and under-represent those from private hospitals (12%). Although this study identifies perceived facilitators and barriers to confidence, the findings should be considered hypothesis-generating in terms of the ability of any training to improve confidence. The impact of a particular training activity on confidence would require further research. This study did not investigate other commonly performed important airway procedures such as bag valve mask ventilation, elective percutaneous tracheostomy, and extubation; future research and training evaluations should also consider these procedures. In addition, it is important to note that this study only investigated confidence, not competence; the two are not necessarily correlated. In fact, two participants quite rightly highlighted this paradox in their responses, one arguing that no-one should feel confident if they suddenly encounter a CICO situation. Nevertheless, confidence in performing a life-saving procedure is likely important in determining its success (especially for time-limited procedures such as FONA). This study also did not investigate clinical decision making; all the scenarios were directive in which procedure was to be performed. This is not to disregard the critical importance of training and experience in clinical decision making regarding airway management, with failure of judgement identified in the NAP4 audit as a contributor to airway complications.^7,8

Finally, it is important to place this study in the context of current times. Intensive care specialists performed the intubations for most patients with COVID-19 in Australia an d New Zealand,²⁰ highlighting their current need for airway proficiency. Changes in intensive care practice may alter volumes of practice and, therefore, airway management confidence in the future. Australian intensive care specialists are highly trained specialists who are responsible for managing units usually with a variety of patients, and who are often responsible for performing their own procedures. This study has provided valuable insight into these clinicians' airway management confidence, demonstrating reduced confidence for two more complex and less common procedures. This finding may help guide the development of CPD programs both within hospitals and the specialty more broadly.

Competing interests

All authors declare that they do not have any potential conflict of interest in relation to this manuscript.