The Difficult Airway Society (DAS) released their first intubation guidelines in 2004 with the aim of providing a simple, stepwise algorithm which enhanced situational awareness and decision-making for unanticipated failed intubation [19].
The Vortex approach is another commonly used cognitive aid. Dr Nicholas Chrimes, an anaesthetist in Melbourne, created the Vortex approach with the intention of providing a simple, graphical “high acuity implementation tool” [20].
The Vortex cognitive aid moves the operator through three broad airway management strategies with the goal of restoring alveolar oxygen delivery via face mask, supraglottic airway device (SAD) or endotracheal tube. It recommends that when a “best effort” at all three techniques has failed, and despite optimisation of each approach, then a front of neck access (FONA) is required.
The Green Zone located outside the Vortex provides an opportunity for the team to pause and regain situational awareness to aid further decision making, whenever alveolar oxygen delivery is restored (defined as an end-tidal CO2 waveform or rising oxygen saturations). During this time, oxygenation can be maximised, additional help and equipment assembled, and a plan established prior to repeated instrumentation of the airway.
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In this way, the Vortex approach prevents task fixation which could potentially turn a “can’t intubate, can oxygenate” situation into a “can’t intubate, can’t oxygenate” scenario. Despite the widespread uptake of airway algorithms, clinicians still find it difficult to progress through the algorithm in stressful and high-stakes situations [21,22]. Repeated mental and practical rehearsal needs to occur in order to successfully implement them.
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The DAS algorithm and the Vortex approach can be used together to maximise team success during emergency airway management. Using this approach, the DAS algorithm is used to verbalise the pre-induction plan for securing the airway (Plan A, B, C and D), while the Vortex approach is then used as a cognitive aid if there is need to progress through the different lifelines in case of unexpected difficult airway.
CICO Rescue
The progression of a challenging airway to a CICO situation is generally insidious, and often without a clear juncture, and therefore it can be difficult for the team to recognise and act quickly.
Because of this, it is important that priming of the team for the potential of a CICO situation occurs early when it is clear that the case is not straightforward. This occurs in a "ready - set - go" sequence, escalating through these steps when each subsequent optimal supraglottic attempt fails.
Once optimal attempts at all three lifelines have failed then emergency FONA access should be performed. It is crucial to appreciate that neither the DAS nor Vortex guidelines specify an oxygen saturation limit below when this should be attempted – the emphasis is that further non-surgical airway attempts are likely to be futile and therefore FONA is inevitable.
Further Reading
It is essential that you become familiar with the core themes in each of the three difficult airway guidelines in clinical use in Australia:
