Emergency Airway Skills Fade in Six Months, Simulation Study Finds

When a patient on the operating table or in the emergency department cannot be intubated and cannot be oxygenated, the situation is known in anesthesia circles as CICO — cannot intubate, cannot oxygenate. It is among the most feared emergencies in all of medicine, because without an immediate surgical airway the brain begins to suffer irreversible injury within minutes. The definitive rescue maneuver is a cricothyroidotomy: an incision through the cricothyroid membrane in the neck to establish an airway below the obstruction. Yet this procedure is performed so rarely in real clinical practice that most physicians will never encounter a genuine case during their entire training. That rarity is precisely what makes the question of how long the skill survives after a single training session so consequential, and it is the question a team of French researchers set out to answer with a rigorously designed randomized crossover trial.

The study, conducted at the Centre Hospitalier Régional Universitaire in Nancy, France, and published in BMC Medical Education, enrolled first-year residents in anesthesiology and emergency medicine. These are the physicians most likely to be called upon to perform an emergency front-of-neck airway when a standard intubation fails. The research team, led by Côme Slosse and Guillaume Favrel of the Department of Anesthesiology and Critical Care, with senior author Hervé Bouaziz, designed the investigation as a prospective, randomized, crossover study with two sessions separated by exactly six months. The crossover design meant that each participant trained on and was assessed in both techniques — the open surgical approach and the percutaneous approach — allowing the investigators to compare retention directly within the same individuals rather than between different groups of trainees.

The two techniques differ fundamentally in their mechanics. The surgical cricothyroidotomy, often taught as the scalpel-bougie-tube technique, involves a scalpel incision through the skin and the cricothyroid membrane, insertion of a bougie — a flexible introducer — into the trachea, and railroading of a cuffed tube over the bougie into the airway. The percutaneous approach, by contrast, uses a needle or cannula inserted through the membrane, followed by a wire-guided Seldinger technique to place the airway device. International guidelines, including those from the Difficult Airway Society, generally favor the surgical technique in true CICO emergencies, citing its speed and reliability. But guidelines are only as effective as the hands that execute them, and the durability of those hands after simulation training has remained an open question.

During the first session, participants received standardized theoretical instruction followed by hands-on practice on low-fidelity models, after which their baseline performance was measured. Six months later, the residents returned for a retention assessment that was deliberately more demanding: a high-fidelity simulation of a CICO scenario under realistic conditions. The primary outcome was a metric the authors called the retention index, defined as the proportional change in performance time between the two sessions. Secondary outcomes included absolute performance time, whether the cricothyroidotomy was successfully completed, retention of the individual procedural steps as scored by standardized checklists, self-reported confidence, and perceived stress. In a methodological touch that sets this study apart, the researchers also attached continuous ECG Holter monitors to the participants, tracking heart rate throughout the procedure as an objective physiological marker of stress.

Of the residents enrolled, thirty-one — seventy-nine percent of the cohort — completed both sessions, and twenty-nine of those, or ninety-four percent, successfully performed at least one of the two techniques at the six-month mark. The headline finding was one of equivalence: the retention index showed no statistically significant difference between the surgical and percutaneous techniques, at 0.93 versus 1.03 with a p-value of 0.92. In other words, both skills decayed at roughly the same proportional rate over the six-month interval. Neither approach could claim an advantage in pure retention, a result that might appear to settle the debate in favor of neutrality between the two methods.

But the secondary outcomes told a more nuanced and arguably more important story. Performance time increased significantly for both techniques after six months, with p-values below 0.001, confirming substantial skill decay across the board. Yet even after that decay, the surgical approach remained markedly faster at the retention session, with a mean time of 68 seconds compared with 113 seconds for the percutaneous technique — a difference that was highly statistically significant. In a genuine CICO emergency, where every second of hypoxia counts against a shrinking window of neurological safety, a forty-five-second difference in completion time is not a statistical curiosity; it is potentially the difference between an intact brain and a devastated one.

The residents also retained the individual procedural steps of the surgical technique significantly better than those of the percutaneous approach, with a p-value of 0.037, and their self-confidence was significantly higher for the surgical method, at p equal to 0.008. Confidence matters in emergencies for reasons that go beyond psychology: hesitation and second-guessing consume time, and a clinician who doubts the next step of a procedure is slower and more error-prone than one who moves through a well-rehearsed sequence. The heart rate data added an objective dimension to the stress picture. Heart rate rose significantly during the simulations, with p-values below 0.001, confirming that the high-fidelity scenario genuinely induced physiological stress — but the increase did not differ between the two techniques, suggesting that the stress response itself does not differentially favor one method over the other.

The study’s limitations are worth acknowledging. The cohort was modest in size, thirty-one completers is enough to detect the reported differences but not enough to exclude smaller effects, and the assessments were performed on simulation models rather than in human patients, which is of course ethically the only option for this procedure. The participants were first-year residents, so the findings speak most directly to early-stage trainees rather than experienced clinicians. Low-fidelity models were used for initial training while a high-fidelity scenario was used for retention testing, a design choice that the authors made deliberately to test transfer to a more realistic context, but which introduces a change in testing conditions between sessions. None of these caveats, however, undermines the central and sobering conclusion: after a single training session, both techniques showed marked performance decay at six months.

That conclusion carries a direct message for training programs worldwide. If critical care residents lose a substantial portion of their cricothyroidotomy proficiency within half a year of a single simulation session, then the common practice of teaching the procedure once during a rotation or an annual airway course may be insufficient to guarantee competence at the moment it is needed. The authors explicitly emphasize the need for more frequent retraining, and their data suggest that the interval between refresher sessions should be shorter than six months. The finding also aligns with a broader literature on procedural skill decay, which has repeatedly shown that infrequently performed invasive procedures are vulnerable to rapid erosion of both speed and accuracy, particularly in the early phase after initial acquisition.

The study’s practical implications may extend to which technique programs should prioritize. Given that retention was equivalent but the surgical approach was faster, better retained in its procedural steps, and associated with greater confidence, the authors suggest that these secondary advantages may support the surgical technique’s preferential use and its prioritization in simulation-based airway training curricula. This would place the empirical evidence in line with existing guideline recommendations, giving educators a data-driven rationale for concentrating scarce training hours on the scalpel-bougie-tube sequence. For a procedure that most physicians will perform at most once or twice in a career, and always under the most extreme time pressure medicine can produce, the message of this study is unambiguous: the skill you do not refresh is the skill you do not have, and the six-month clock starts ticking the moment the training session ends.

Subject of Research: Retention of emergency cricothyroidotomy skills after simulation-based training in critical care residents

Article Title: Six-month retention of surgical versus percutaneous cricothyroidotomy skills: a randomized crossover study in critical care residents

Article References: Slosse, C., Favrel, G., Bourst, P., Fantin, L., Hani, H., Audibert, G., & Bouaziz, H. (2026). Six-month retention of surgical versus percutaneous cricothyroidotomy skills: a randomized crossover study in critical care residents. BMC Medical Education. https://doi.org/10.1186/s12909-026-10493-3

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10493-3

Keywords: cricothyroidotomy, CICO emergency, airway management, simulation training, skill retention, medical education, resident training, anesthesiology, emergency medicine, randomized crossover study, surgical airway, performance decay