Comparison of Peyton's Four-Step Approach and Rapid Cycle Deliberate Practice in Basic and Advanced Airway Management: A Simulation-Based Study

Background Simulation-based training plays a critical role in the acquisition of airway management skills in undergraduate medical education. Peyton's Four-Step Approach (PFSA) and Rapid Cycle Deliberate Practice (RCDP) are two structured, evidence-based methodologies used in simulation training. While both have shown educational benefits, few studies have directly compared their effectiveness across both basic procedures, such as laryngeal mask airway (LMA) placement and endotracheal intubation (ETI), and complex procedures, such as fiberoptic intubation (FOI), especially in time-limited massed practice formats. Methods Fifty-nine third-year medical students with no prior experience in airway management participated in this simulation-based study. They were divided into two cohorts: one trained using RCDP and the other using PFSA. Each cohort received three weekly sessions focused on LMA, ETI, and FOI, respectively, with individualized hands-on training. Final evaluations were conducted using the Objective Structured Assessment of Technical Skills (OSATS) for LMA and ETI, a Global Rating Scale (GRS) for bronchoscope handling, and a 10-item checklist for FOI. Statistical analysis included t-tests, Mann-Whitney U, chi-squared or Fisher's exact tests, and Cronbach's alpha for instrument reliability. Results PFSA resulted in significantly higher OSATS scores for LMA placement (38.06 ± 6.67 vs. 31.93 ± 7.70, p = 0.0017), with a higher proportion of non-competent participants in the RCDP group (p = 0.009). In contrast, RCDP outperformed PFSA in ETI OSATS scores (67.00 ± 12.32 vs. 58.93 ± 11.87, p = 0.012) and in the proportion of students achieving mastery (p = 0.013). For FOI, RCDP led to significantly better results on the GRS (14.73 ± 4.65 vs. 9.66 ± 2.79, p < 0.0001) and the procedural checklist (median: 6.0, interquartile range (IQR): 5-7 vs. median: 4.0, IQR: 3-6, p = 0.0021). No participants reached mastery in FOI, but the RCDP group had significantly more moderately competent students (p = 0.0194) and fewer non-competent participants (p = 0.0003). Reliability of assessment instruments was confirmed with Cronbach's alpha values above 0.70. Conclusion PFSA was more effective for teaching basic skills such as LMA placement, likely due to its stepwise instructional design. RCDP showed superior outcomes in ETI and FOI, supporting its use in complex procedures that benefit from iterative practice and immediate feedback. These findings highlight the importance of tailoring simulation-based training methods to the complexity of the procedure and the learners' needs, particularly in programs with limited training time, and underscore the value of incorporating follow-up assessments to evaluate long-term retention and the durability of training effects.