Cognitive tool for dealing with unexpected difficult airway

Abstract

Editor—I would like to draw your attention to a novel cognitive tool for dealing with the unexpected difficult airway. The ‘Can’t Intubate, Can’t Ventilate’ airway crisis is arguably the most time-critical emergency that is encountered in the operating theatre. It is also one of the few causes of morbidity and mortality that are directly related to the conduct of anaesthesia. Therefore, considerable effort is made by the anaesthetic profession to establish guidelines and procedures to avoid failures in airway management. One important aspect of that work is the difficult airway algorithms that are published, and regularly revised, by national and regional bodies.1Henderson JJ Popat MT Latto IP Pearce AC Difficult Airway Society guidelines for management of the unanticipated difficult intubation.Anaesthesia. 2004; 59: 675-694Crossref PubMed Scopus (841) Google Scholar 2American Society of Anesthesiologists: practice guidelines for management of the difficult airway: an updated report.Anesthesiology. 2003; 98: 1269-1277Crossref PubMed Scopus (1541) Google Scholar All anaesthetists receive training in airway management and the use of different devices and adjuncts devised to facilitate it. Despite all this training and the existence of algorithms, clinicians sometimes fail to act quickly enough, or at all, to resolve the situation. The endpoint in all difficult airway algorithms—the emergency surgical airway (ESA)—is a very rare procedure, and it can be hard to overcome the resistance to perform it for an inexperienced or unprepared anaesthetist. Recognizing these obstacles to effective management of the failed airway, and also the fact that not all attempts at airway management are made in the operating theatre, two physicians have developed the Vortex Approach3Chrimes N Fritz P The Vortex Approach: Management of the Unanticipated Difficult Airway. Monash Simulation, 2013Google Scholar (http://vortexapproach.com/Vortex_Approach/Vortex.html). The Vortex is meant to be used as a ‘high stakes cognitive aid’, that is, as an easy to remember guide to quick and focused decision-making in an airway emergency. It emphasizes the importance of establishing effective alveolar oxygen delivery and can be used regardless of which airway management strategy is chosen initially. The tool is presented as a funnel divided into three segments (Fig. 1), each representing one of the non-surgical airway techniques—face mask, laryngeal mask, and tracheal tube. After an optimal attempt has been made using the planned technique, the operator proceeds with the next, while conceptually sliding down the slope of the funnel (hence the name ‘Vortex’). It is often necessary to make more than one attempt at each technique before declaring that an ‘optimal’ attempt has been made. Different manipulations, adjuncts, or both can then be used to improve the chances at success. When optimal attempts at all three non-surgical techniques have been made, the operator moves into the centre and bottom of the funnel, which represents the ESA. The Vortex Approach thus helps the clinician to move forward, avoiding repeated attempts at methods that have already proven unsuccessful. I recently encountered an unexpected difficult airway, where I ended up performing an emergency tracheostomy—the first and hopefully last one of my career. Luckily, the patient survived neurologically intact. Even though the outcome would have been the same regardless of which difficult airway algorithm had been used, the simplicity of the Vortex made the decision-making faster and more focused. This was also noticed by the rest of the team members, who later commented on the apparent calm and resolve that I demonstrated. Teaching the Vortex Approach to anaesthetists and other healthcare professionals likely to encounter airway emergencies should be considered. None declared. Written consent has been obtained from the patient before submission. Download .zip (.0 MB) Help with zip files Download .zip (.0 MB) Help with zip files Download .zip (.0 MB) Help with zip files Download .zip (.0 MB) Help with zip files