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Experience in awake fibreoptic intubation

El-Boghdadly et al. stated ‘contemporary data relating to training provision for AFOI in the UK is significantly lacking’ [1]. The 4th National Audit Project (NAP4) reported underuse of awake fibreoptic intubation (AFOI) in the management of difficult airways, with likely contributory factors including lack of experience and familiarity [2]. Older generations of anaesthetists were taught how to deal with difficult airways using direct laryngoscopy, blind nasal intubation and ‘gold standard’ awake fibreoptic intubation. However, younger anaesthetists rely on new technologies such as videolaryngoscopy and high-flow nasal oxygenation, with a real risk that AFOI may be abandoned [3]. Traditionally, airway management skills were acquired through ‘on-the-job’ experience, but with the implementation of the European Working Time Directive in 1998, trainees frequently report less than satisfactory quality of airway training programmes across theUK [4, 5]. Concerns over the past 20 years about the quality of training in airwaymanagement in the UK have remained the same [4]. A recent London-wide questionnaire survey that we undertook found that lack of case-load experience was the major factor that hindered anaesthetists (n=117) from performing AFOI competently. There is evidence to suggest an acceptable level of competence is achieved after 10 fibreoptic intubations [5], but less than a quarter of our respondents achieved that number. El-Boghdadly et al. found that AFOI complication rates were related to operator experience, irrespective of training grade [1], and yet almost half of our respondents had not performed AFOI in the last year. Currently, the provision of formal airway training in AFOI is highly variable. Clearly, anaesthetists, trainees and non-trainees should maintain the psychomotor skills and confidence necessary to perform AFOI. This could be achieved through mandatory attendance at local or regional airway courses, which could then be reflected in their annual appraisal. Most importantly, the technical and non-technical skills of AFOI need to be acquired through appropriate airway courses andmaintained in a clinical environment with sufficient case numbers to feel comfortable in managing AFOI in a time of crisis.