Airway Ultrasound Training Lacks Global Standardization Despite Clinical Utility

The Evolution of Precision Airway Management

Modern airway management increasingly relies on point-of-care ultrasound to mitigate the risks of unexpected difficult laryngoscopy, which remains a significant cause of perioperative morbidity [1, 2]. Beyond simple anatomical screening, sonography provides a rapid, highly accurate method for confirming endotracheal tube placement in emergency settings, yielding a pooled sensitivity of 0.98 and specificity of 0.94 [3]. Clinical evidence also suggests that ultrasound-guided measurements, such as hyomental distance (the distance between the hyoid bone and the chin, used to predict difficult intubation), offer superior precision over traditional weight-based criteria for selecting pediatric airway devices [4]. Despite these clear diagnostic advantages and the inclusion of ultrasound in multi-society practice guidelines for the difficult airway, the pathway to clinical proficiency for the practicing anesthesiologist is not yet standardized [5]. A new scoping review now examines the current landscape of anesthesia training programs to identify how this essential skill is being taught and where educational gaps persist.

Mapping the Educational Landscape

To evaluate the current state of anesthesia education, the researchers conducted a scoping review (a type of evidence synthesis used to map existing literature on a broad topic and identify key concepts or research gaps). On August 1, 2025, the authors performed a comprehensive search of MEDLINE and Embase via the Ovid interface. To ensure the findings reflected modern clinical practice, the search was limited to peer-reviewed publications released after the year 2000. In addition to traditional journal articles, the researchers sought out grey literature (materials such as government reports, professional society guidelines, or institutional curricula that are not published in standard commercial journals). This search targeted professional society websites and national or institutional training documents to capture a more complete picture of how airway ultrasound is integrated into medical education. The study established specific inclusion criteria, focusing on literature that reported on airway ultrasound training programs, educational approaches, or formal competency frameworks. Once the relevant documents were identified, the researchers extracted data regarding curriculum content, methods of teaching and assessment, and various implementation factors. These data were then subjected to a descriptive analysis (a statistical method used to summarize and describe the basic features of a dataset) to characterize the current state of the field. The initial search strategy was broad, yielding 215 peer-reviewed documents and 17 grey literature documents. After a rigorous screening process and the application of exclusion criteria, the researchers identified 11 records for final inclusion in the review. This final cohort consisted of eight peer-reviewed studies and three grey literature documents. By synthesizing these sources, the authors aimed to map the current landscape of airway ultrasound training and identify specific gaps that may hinder the development of standardized educational protocols. For the practicing clinician, understanding these gaps is the first step toward establishing the formal training pathways necessary to ensure that ultrasound-guided airway management becomes a reliable, universal skill in anesthesia departments.

Current Curricular Focus and Instructional Methods

Among the 11 records identified in the scoping review, 10 documents specifically described the integration of airway ultrasound into anesthesia training programs. These programs utilized airway ultrasound for three primary clinical applications: performing preoperative airway assessment, confirming successful tracheal intubation, and identifying anatomical variations that might complicate management. To ensure clinicians developed both theoretical knowledge and technical proficiency, all programs incorporated a dual-modality instructional design consisting of didactic and practical elements. The didactic component (classroom-based or lecture-style instruction of theory and anatomy) provided the foundation for the subsequent hands-on training. The practical training components within these curricula utilized three distinct modalities to build procedural skill: simulation, live model scanning, and supervised clinical practice. This hands-on instruction was highly focused on high-stakes clinical tasks. Specifically, the curriculum content emphasized upper airway assessment, the confirmation of tracheal intubation, and the identification of landmarks for front-of-neck access (the emergency placement of an invasive airway through the cricothyroid membrane). By prioritizing these areas, the training programs aimed to equip anesthesiologists with the sonographic skills necessary to manage both routine and emergency airway scenarios where traditional physical examination or laryngoscopy might be insufficient.

Assessing Competency and Identifying Barriers

To ensure that clinicians achieve technical proficiency, the identified training programs utilized diverse evaluation methods to measure trainee progress. Competency assessment included both written and practical examinations, which allowed instructors to evaluate both the theoretical understanding of sonographic anatomy and the manual dexterity required for accurate image acquisition. Furthermore, portfolio requirements were present in four national programs, serving as a formal record of clinical logs and reflective practice (a structured method of reviewing one's own clinical experiences to improve future performance) to document a trainee's longitudinal experience and skill acquisition in airway sonography. Despite the clinical utility of these techniques, the researchers found that the integration of airway ultrasound into anesthesia training programs remains inconsistent globally. The review highlighted considerable international variation in curriculum content and delivery, with no unified standard for what constitutes adequate training across different regions. In many jurisdictions, formal teaching remains inconsistent and often optional, meaning that many anesthesiologists may complete their residency without structured exposure to these diagnostic tools, depending instead on local interest or ad hoc learning opportunities. Several systemic factors hinder the widespread adoption of these educational programs within the medical community. The study found that implementation is constrained by limited faculty expertise, equipment availability, and competing curricular demands within already crowded medical training schedules. To address these gaps and ensure a high standard of patient care, the authors conclude that establishing standardized competencies and evidence-based assessment frameworks is essential for successfully embedding airway ultrasound into routine anesthesia practice. Moving toward a structured, requirement-based model will be necessary to overcome the current fragmentation in global anesthesia education.

References

1. Gomes SH, Simões AM, Nunes AM, et al. Useful Ultrasonographic Parameters to Predict Difficult Laryngoscopy and Difficult Tracheal Intubation-A Systematic Review and Meta-Analysis.. Frontiers in medicine. 2021. doi:10.3389/fmed.2021.671658

2. Ferszt P, Hill J, Larson S. Ultrasonography relative to Cormack-Lehane in predicting difficult laryngoscopy: a systematic review of diagnostic test accuracy.. JBI evidence synthesis. 2021. doi:10.11124/JBIES-20-00141

3. Farrokhi M, Yarmohammadi B, Mangouri A, et al. Screening Performance Characteristics of Ultrasonography in Confirmation of Endotracheal Intubation; a Systematic Review and Meta-analysis.. Archives of academic emergency medicine. 2021. doi:10.22037/aaem.v9i1.1360

4. Arafa SK, ElSharkawy MS, Shaheen MM, Shama A. Hyomental distance measured ultrasonography versus weight-based criteria for laryngeal mask size selection in children: a randomized controlled trial.. BMC anesthesiology. 2025. doi:10.1186/s12871-025-03303-8

5. Apfelbaum JL, Hagberg CA, Connis RT, et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway *. Anesthesiology. 2021. doi:10.1097/aln.0000000000004002