The Difficult Airway Society (DAS) has given accreditation marks of quality to Difficult Airway.

The Difficult Airway Society (DAS) has given accreditation marks of quality to Difficult Airway courses in several institutes and companies worldwide. The Health Way Academy, a company based in Portugal delivers a Difficult Airway course included in a program of Critical Patient postgraduate studies, which is accredited by the DAS. A new resource tool used on these courses is BodyInteractTM, a simulator with dynamic software that helps healthcare learners and professionals to master clinical knowledge. It comprises a variety of clinical scenarios with different levels of involvement and differentiation. The software can simulate emotions and give real-time feedback. Also, with this software, it is possible to create different levels with different grades of difficulty, and to use its range of complexities to adapt the teaching methods for each of the courses within the university curriculum.

As an example, we bring you a case of a 24-year-old male, without comorbidities, which begins with a severe tongue angioedema:

1 - Initially the simulator gives an introduction with all of the phenotypic characteristics of the patient, including past medical history, weight, height and race, among others. This information gives some clues for the differential diagnosis.

2 – A short anamnesis is given, with the focus on the main symptoms, followed by a basic initial approach based on information such as the patient’s vital signs. This information allows the learners to establish an initial “picture” of this scenario. In this example, blood pressure is 132/89mmHg, heart rate is 102 bpm, respiratory rate is 26 breaths per minute, temperature (tympanic) is 37.4ºC, peripheral oxygen saturation is 99% (with FiO2 of 21%), and blood glucose is 102 mg/dL. The simulator also gives a summarized analytic evaluation of the blood, including ionogram, hemoglobin and other relevant parameters.

3 – After this initial information, a more systematic ABCDE approach is taken, with detailed questions and examination of each system, giving the classic priority to airway and breathing, as should be the case with a real critical patient. In our case, the main semiological finding is the partial obstruction of the airway by the swollen tongue, tonsils and inflammation of the oropharynx. As time advances, the situation becomes clearer, and the diagnosis of angioedema/anaphylactic reaction needs to be established. The patient’s blood pressure starts dropping, he becomes desaturated, his heart rate increases to over 130-140 beats per minute, the swelling and dyspnea worsen and the patient’s voice becomes hoarse. It is also evident that he becomes more anxious.

4 – It is time to deal with the situation! The team has a race against time (with a real clock appearing on the monitor) to decide on priorities, medications and airway approach possibilities (inducing some pressure for our real-life learners). This is a point where, usually, a natural team leader stands out, and on some occasions discussions and disagreements may start. This is a fundamental aspect of training in real-life approaches to difficult airway situations. Dealing with this also prepares students for real-life divergences of opinion and conflict.

The huge horizontal plasma table that BodyInteractTM has allows everybody to forget that it is a training simulation, and the challenge becomes real. In our case, an obvious approach would include the administration of intramuscular adrenaline, corticosteroids, antihistamines and vascular filling with crystalloids. In addition, the priority is the airway approach, and an advanced airway approach with subsequent invasive mechanical ventilation may be the only plausible solution. The software allows the user(s) to choose this approach in an ABCDE system. Every treatment takes a certain time, so if the learner chooses a procedure, the clock “cuts” that time, to reflect the amount of time taken by the procedure in real life.

5 – At the end of our case, if the approach is not appropriate, the patient may die. After the closure of the case, the main points need to be highlighted and learnt. The teacher intervenes and the learners explain their decisions and their priorities. They are encouraged to think about the choices that they did not make but which could have made the difference. In this phase, the horizontal table allows the users to run through the entire scenario and permits the students to watch the different stages of evolution, helping them to organize and systematize the information, and making them more prepared for future similar situations in real life.

This clinical case is a good example of this tool’s potential. BodyInteractTM is already used in several teaching environments, not only on our Difficult Airway course with DAS accreditation. It helps to create a dynamic situation, facilitating simulation scenarios in different places, with a simple table screen in view but with complex software behind it. Although the scenario is simulated, the interaction between students, the information exchange and the debriefings are real, contributing towards more sustained learning.

Our students’ feedback has been highly satisfactory. On any course, BodyInteractTM can be used between face-to-face lessons, capturing the learners’ interest and maintaining their focus on the content. The portability of this device is one of its main advantages, removing the dependence on a simulation laboratory. BodyInteractTM may also be a good acquisition for other DAS teaching courses. Although it does not teach any technical skills (because it is 100% virtual), it will undoubtedly make a contribution to the development of non-technical skills such as leadership, conflict management, device selection, prioritization and medication usage.

For further information, please consult the BodyInteract website (https://bodyinteract.com), where you can experience a simulation online and the link to our course: https://vimeo.com/397456490/b9f2d25233.

Authors: MENDONÇA, Mauro (Dr.) and MOLEIRO, Wilson (Nurse).

Organization: Academia Health Way and Body Interact, Portugal.

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