The Vortex model: A different approach to the difficult airway | Revista Española de Anestesiología y Reanimación (English Edition)

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A) Visión frontal. B) Vista lateral. Imágenes usadas con permiso de Nicholas Chrimes, <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="http://vortexapproach.org/">http://vortexapproach.org/</a>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Charco-Mora, R. Urtubia, L. Reviriego-Agudo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Charco-Mora" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Urtubia" ] 2 => array:2 [ "nombre" => "L." 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(A) frontal view, (B) lateral view (reproduced with permission from Nicholas Chrimes)." ] ] ] "textoCompleto" => "IntroductionSuccessful airway management continues to be a fundamental skill for anaesthesiologists, and these specialists are considered the best qualified to deal with difficult airway situations. However, problems stemming from poor airway management are still the most common cause of anaesthesia-related morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0295">1</a>Management of a difficult airway is an example of a typical predictable clinical situation, even though a difficult airway in a specific patient might not be foreseen. All specialists involved in airway management know that an unanticipated difficult airway can be encountered at any time. From the perspective of the patient (and legal regulations), a difficult airway can be considered a typical, quantifiable and predictable complication.<a class="elsevierStyleCrossRef" href="#bib0300">2</a> Similarly, although infrequent in routine clinical practice, surgical teams must be prepared to deal with and successfully resolve an airway crisis. Inappropriate clinical management can worsen the situation and further restrict airway access,<a class="elsevierStyleCrossRef" href="#bib0305">3</a> and ignorance and inadequate training contribute to the appearance of complications in up to 50% of cases.<a class="elsevierStyleCrossRef" href="#bib0310">4</a>Generally speaking, there are 4 airway management approaches or strategies:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-Facial approach: including the different oxygen therapy techniques (ranging from common nasal cannula to high-flow systems), manual ventilation with a face mask (with adjuvants), and different forms of ventilatory support using a facemask (such as non-invasive mechanical ventilation, Oxylator, etc.).</li><li class="elsevierStyleListItem" id="lsti0010">-Transglottic approach: involves introducing a device into the trachea through the glottic opening. Tracheal intubation is the gold standard for airway management.</li><li class="elsevierStyleListItem" id="lsti0015">-Supraglottic (or extraglottic) approach: involves the use of devices that seal the hypopharynx to deliver positive ventilation. Some of these supraglottic devices include adjuvants to prevent gastric aspiration (such as a gastric suction channel or drainage tube).</li><li class="elsevierStyleListItem" id="lsti0020">-Infraglottic approach (front of neck access, or FONA): involves accessing the airway by means of an incision that, due to the anatomy of the neck, is usually made through the cricothyroid membrane (cricothyroidotomy).</li></ul><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the failure rates of the different airway approaches. It is important to note that the failure of 1 approach increases the possibility of failure of the next. For example, in an obese patient with positive predictors of difficult intubation, the likelihood of ventilation difficulty is greater (including ventilation through a supraglottic airway); likewise, percutaneous access to the airway can also be complicated.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Fortunately, when 1 approach fails, another can be tried, and all can be used indistinctly to secure the airway and oxygenate the patient.The number of anaesthesia-related complications has declined in recent decades. Serious complications caused by hypoxaemia after intubation failure, such as permanent neurological damage or death,<a class="elsevierStyleCrossRefs" href="#bib0315">5,6</a> have spurred researchers to develop new strategies and technologies to improve the standard of care and improve patient safety.Efforts to improve airway management have led to the development of new technologies. These include videolaryngoscopes (with standard or difficult intubation blades), various optical devices that incorporate the latest CMOS technology (such as video stylets and video endoscopes), as well as sophisticated, state-of-the-art supraglottic devices, even with passive oxygen insufflation. To these can be added the latest techniques for denitrogenation or oxygenation through high flow nasal cannula (THRIVE), together with advanced systems for monitoring tissue oxygenation and different ventilatory methods (neural control of ventilation). Scientific societies, for their part, have developed their own treatment algorithms to implement all these new technologies in a structured manner, based on expert consensus and the best available evidence.Despite all these efforts, incorrect management of an unanticipated difficult airway still results in serious complications. Some of these problems stem from our approach to decision-making and our reaction to these highly stressful crisis scenarios.<a class="elsevierStyleCrossRef" href="#bib0295">1</a>Human factors and resource management during an airway crisisWhy are technical skills and algorithms insufficient to manage the most critical situations? The fact is that stress impacts decision-making and performance.<a class="elsevierStyleCrossRef" href="#bib0325">7</a> To explain this, we must first define “the human factor” and “crisis resource management” (CRM).There is currently no evidence to show the benefits of CRM tools in airway management.<a class="elsevierStyleCrossRef" href="#bib0330">8</a> However, CRM has been successfully tested in other areas where potentially high-risk situation can arise (for example, in the nuclear industry, the aviation industry, etc.),<a class="elsevierStyleCrossRefs" href="#bib0335">9–11</a> and since the 90s, when Gaba et al.<a class="elsevierStyleCrossRef" href="#bib0350">12</a> adapted these new concepts to the field of anaesthesia (Anaesthesia CRM), they have been used in airway management.The human factor is related to personal and team performance within a given system.<a class="elsevierStyleCrossRef" href="#bib0355">13</a> This means that humans are fallible, and our performance during a crisis is affected by personal and environmental factors, external pressure, and cognitive overload.<a class="elsevierStyleCrossRef" href="#bib0360">14</a> The most important personal factors are: fatigue, lack of sleep, emotional disturbance, and inexperience.<a class="elsevierStyleCrossRefs" href="#bib0365">15,16</a> The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society reported that human factors contributed to adverse outcomes in 40% of all cases involving serious or fatal injuries.<a class="elsevierStyleCrossRef" href="#bib0295">1</a>The concept of anaesthesia CRM refers to the non-technical skills required for effective teamwork in a crisis situation.<a class="elsevierStyleCrossRef" href="#bib0375">17</a> Although Gaba described 15 key principles, team performance during a crisis is determined by 4 decisive factors: situational awareness, decision-making, task management, and teamwork. In an airway crisis, cognitive overload often means that physicians “can’t see the forest for the trees”, and become obsessed with a single task (fixation error).Therefore, it is important to consider human factors and manage them appropriately,<a class="elsevierStyleCrossRef" href="#bib0380">18</a> since CRM training has been shown to improve performance<a class="elsevierStyleCrossRef" href="#bib0385">19</a> and with it, patient outcomes.<a class="elsevierStyleCrossRef" href="#bib0390">20</a>Why do difficult airway guidelines and algorithms fail?Several different clinical guidelines for difficult airway management have been drawn up by the leading international scientific societies. All are based on a critical review of the scientific literature, together with consensus recommendations put forward by a panel of experts approved by the different national societies that regularly publish and update such guidelines.<a class="elsevierStyleCrossRefs" href="#bib0395">21–25</a> They provide a standardised approach to common clinical situations, such as known and unanticipated difficult airway, and a final solution for can’t intubate, can’t oxygenate cases (CICO),<a class="elsevierStyleCrossRef" href="#bib0420">26</a> in addition to important recommendations for safe extubation.<a class="elsevierStyleCrossRefs" href="#bib0425">27,28</a> For this purpose, they recommend different strategies and intubation or ventilation devices, depending on the experience or the state of the art. However, despite the widespread use of these algorithms, there is no strong evidence to show the degree of benefit of any particular strategy,<a class="elsevierStyleCrossRef" href="#bib0435">29</a> although there is moderate evidence that the use of these guidelines improves airway management.<a class="elsevierStyleCrossRef" href="#bib0440">30</a>The NAP4 report is an in-depth analysis of the factors that contribute to poor airway outcomes, and shows that these are clearly related to the patient's comorbidities or failure to predict the presence of a difficult airway. The report also found other important positive factors, such as good judgement, planning, the right equipment, good communication within the team, and training in airway management techniques.Algorithms outline a sequence of steps to be taken when intubation fails, always prioritising oxygenation and limiting the number of airway interventions to minimise trauma and complications. However, these recommendations often fail for various reasons: clinical inertia, the difficulties of implementing the recommended action within a particular the health system, and limited access to the devices required.<a class="elsevierStyleCrossRefs" href="#bib0445">31,32</a> Burgers et al.<a class="elsevierStyleCrossRef" href="#bib0455">33</a> have shown that the main barriers to guideline implementation are the difficulties involved in learning new techniques or skills and in applying the rescue sequence in practice. Leentjens and Burgers<a class="elsevierStyleCrossRef" href="#bib0460">34</a> conclude that successful implementation of such guidelines depends on creating a team with a shared vision, where all members willingly follow the recommendations and accept them as a meaningful safety strategy.Another reason for guideline inadequacy is their failure of guidelines to address two fundamental questions: how should decisions be made in these highly stressful events? And how the team be organised? We know that algorithms are intended as teaching and learning tools,<a class="elsevierStyleCrossRef" href="#bib0465">35</a> and although they have also been useful in crisis management planning, they are presented in a format that is of little use to a highly stressed team in the midst of an airway crisis.<a class="elsevierStyleCrossRef" href="#bib0470">36</a> Only the latest DAS guidelines recommend that clinicians “stop and think” to avoid fixation errors in stressful situations.Finally, as the latest DAS guidelines acknowledge: “The complexities of difficult airway management cannot be distilled into a single algorithm”. The recommended actions are difficult to implement in a stressful, emergency airway situation.This is why following guidelines and implementing algorithms do not in themselves guarantee a successful outcome or prevent serious complications.What are cognitive aids? Are they useful in the management of an airway crisis?Some schematics or flowcharts have been used to help in the management of a series of anaesthesia-related emergencies, such as anaphylactic shock, malignant hyperthermia crisis, etc.,<a class="elsevierStyleCrossRef" href="#bib0475">37</a> in the belief that they will help clinicians improve performance and successfully complete the task. These strategies are called “cognitive aids, or checklists,” and are designed to guide stressed physicians through a sequence of complex steps and prevent them from skipping key actions. Clinicians under stress are less capable of remembering lists of actions, and are more likely to become fixated.<a class="elsevierStyleCrossRef" href="#bib0480">38</a> Checklists and cognitive aids also help reduce errors and maximise effective teamwork. For this to happen, according to Marshall,<a class="elsevierStyleCrossRef" href="#bib0485">39</a> a good cognitive aid must meet the following criteria: (1) Its content must be derived from “best practice” guidelines or protocols; (2) Its design should be appropriate for use in the context of the emergency situation; (3) It should be familiar, in a format that has been used in practice and training; and (4) It should also assist other team members to perform their tasks in a coordinated manner.Perhaps the best known crisis management tool, and one that is easily remembered and implemented, is the Advanced Cardiac Life Support (ACLS) protocol.<a class="elsevierStyleCrossRef" href="#bib0490">40</a> This is a standardised tool that is applicable to all cardiac arrest situations, and can be taught universally to all team members. This tool has been enriched, updated and validated by years of experience in its use worldwide. Unlike the ACLS, the development of an emergency airway management protocol involves unique challenges, principally because the many different management options depend on the skill and preferences of the operator.<a class="elsevierStyleCrossRefs" href="#bib0495">41–43</a> Cognitive aids have been used in emergency scenarios, and although they are widely believed to improve performance,<a class="elsevierStyleCrossRef" href="#bib0510">44</a> this has never been proven.<a class="elsevierStyleCrossRef" href="#bib0515">45</a> Marshall et al.<a class="elsevierStyleCrossRef" href="#bib0520">46</a> performed a prospective study in airway crisis scenarios to evaluate the use of a visual algorithm in a simulated environment. They found no significant differences in technical performance between the groups using and not using the aid, but participants developed better non-technical skills. More recently, Long et al.,<a class="elsevierStyleCrossRef" href="#bib0525">47</a> evaluated the use of cognitive aids in the preparation of emergency paediatric airway equipment, and concluded that its use reduces errors of omission. Burden et al.,<a class="elsevierStyleCrossRef" href="#bib0530">48</a> meanwhile, suggested that technical performance is improved when a team member reads out the contents of the checklist.Anaesthesia non-technical skills (ANTS)The NAP4 report revealed some unexpected facts about the poor airway management practices of British anaesthesiologists, and found evidence of poor or suboptimal performance in over 78% of cases involving airway complications. After analysing of the causes of this chilling finding, the authors listed the main contributing factors as: a poorly trained team, poor communication within the team, and poor clinical judgement in airway management. Good training and communication would improve results.<a class="elsevierStyleCrossRef" href="#bib0295">1</a> These factors are part of the so-called non-technical skills defined by Flin et al. as “the cognitive, social, and personal resource skills that complement technical skills, and contribute to safe and efficient task performance”.<a class="elsevierStyleCrossRef" href="#bib0375">17</a> These ANTS, therefore, define all actions performed by the anaesthesiologist in the operating theatre that are not related to their clinical experience or to the use of drugs and clinical devices.<a class="elsevierStyleCrossRef" href="#bib0535">49</a> These include interpersonal communication, teamwork and leadership skills, together with cognitive aids to take stock of the situation and optimise decision-making.<a class="elsevierStyleCrossRef" href="#bib0540">50</a>Learning these non-technical skills can help improve routine clinical performance, particularly in stressful situations that require the whole team to function correctly, in terms of establishing the action plan, following each step in the algorithm, assigning tasks to each team member, and correctly performing the procedures indicated.<a class="elsevierStyleCrossRefs" href="#bib0545">51–53</a> Both technical and ANTS can be learnt in a simulated environment that allows participants to perfect their skills.<a class="elsevierStyleCrossRefs" href="#bib0560">54,55</a>In conclusion, there is no conclusive evidence that cognitive aids and non-technical skills are effective in anaesthesia, mainly due to the limitations of research into these tools. Therefore, more studies are needed to determine the real contribution of these methods.The VÓRTEX algorithmThe tragic case of Elaine Bromiley occurred in 2005. Mrs. Bromiley was scheduled for endoscopic sinus surgery and septoplasty under general anaesthesia. Apart from slightly restricted cervical mobility, there were no predictors of difficult intubation. However, after a series of ineffective manoeuvres to secure her airway, Ms. Bromiley entered can’t intubate – can’t oxygenate (CICO) status that could not be resolved, and she eventually died.It was probably this unfortunate accident that prompted Nicholas Chrimes to develop a highly sensitive tool called Vortex<a class="elsevierStyleCrossRef" href="#bib0570">56</a> for early detection and resolution of problems stemming from poor airway management. The tool was developed to prevent clinicians from become fixated on a particular technique or tool, to improve decision-making, and promote teamwork and is based on the four airway management approaches described above. To simplify the protocol, each strategy is called a “lifeline” in Vortex, thus intentionally avoiding naming or recommending specific techniques or airway devices. Vortex is intended to be easy to learn and use, and is designed to simplify rescue during an airway crisis. Following the algorithm, clinicians can move from one lifeline to another, based on, but not limited to, tracheal intubation as the standard technique.General descriptionThe Vortex (or funnel-shaped diagram) is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. It consists of three concentric rings representing three zones or layers: the outer ring is the “green zone”, and the centre is the “vortex”, which includes the zone of “emergency front-of-neck access” or CICO rescue area. The central blue ring (vortex) represents the 3 non-surgical lifelines: facemask ventilation, endotracheal tube, and supraglottic airway. The dark blue ring, or emergency surgical airway, is differentiated from the other rings to show the exceptional nature of the FONA approach.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Before the intervention, the patient is breathing spontaneously and is in the outer “green zone”, with normal alveolar oxygenation. This is a “safety zone”.Once the intervention begins with anaesthesia induction, the patient falls into the “vortex zone” where one of the three lifelines must restore and maintain alveolar oxygenation. Airway management can begin with any lifeline and proceed through the subsequent lifelines in any order, according to the plan of action and the objectives of the intervention (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Pre-operative airway assessment and checklistThe Vortex algorithm also includes a pre-operative airway assessment and a safety checklist. The pre-operative assessment is essential, because it will alert the clinician to potential complications and allow him or her to draw up a contingency plan in the event of difficult intubation. This airway assessment or airway prediction takes into account not only anatomical and physiological considerations, but also situational and clinical elements (human factors) that may affect the procedure. This should allow the clinician to evaluate the feasibility of securing the airway using each of the 4 lifelines, and extend the safe apnoea time if any of the techniques should fail.The checklist is the key to safe interventions, proper teamwork, and preventing hypoxia. Checklists should be used in combination with the primary Vortex algorithm and the chosen airway device in the green zone.Attempts and optimisationsEach manipulation of the airway can cause trauma and tissue damage that can further hinder access, and repeated unsuccessful attempts at intubation cause oedema and bleeding that can cause difficulties for ventilation and oxygenation. This is why Vortex recommends making no more than three attempts with each lifeline. In addition, any repeated attempt with a lifeline must incorporate optimisations that have not previously been implemented in order to increase the chances of success.The following is a list of some such optimisations:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025">-Change the position of the head/neck/larynx and of the device itself</li><li class="elsevierStyleListItem" id="lsti0030">-Use the adjuncts that are appropriate for each lifeline</li><li class="elsevierStyleListItem" id="lsti0035">-Changes size/type of airway device</li><li class="elsevierStyleListItem" id="lsti0040">-Suction flow in hypopharynx/oxygen, and/or control/increase oxygen flow</li><li class="elsevierStyleListItem" id="lsti0045">-Muscle tone, administer or up-dose muscle relaxants.</li></ul>This means, firstly, that the clinician must decide which optimisations are most effective before each attempt, and secondly, not all three attempts allowed with each lifeline need to be exhausted if all the optimisations have been implemented.“Best effort”: optimise for success or declare failureThe completion of these 5 optimisation manoeuvres concludes the “best effort” with each lifeline (not all 3 attempts are mandatory). At least one of the attempts should be performed by the most experienced clinician. Completion of the “best effort” in a given lifeline means that the optimisation options have been exhausted and, if alveolar oxygenation has not been restored, the attempt has failed and another approach is needed.When the “best effort” with all three lifelines has failed, the clinician should prepare for the fourth and last lifeline (rescue CICO), even if oxygenation is still adequate.This structured definition of “best effort” with each lifeline is important from two perspectives: it compels the clinician to use pre-defined optimisation manoeuvres, and it is a decision-making tool that facilitates the transition from a failed life to another, possibly successful, approach.CICO status: the fourth rescue techniqueCICO status is also a complementary tool with well-defined steps that prepare the team for rapid initiation of “CICO Rescue” once the best effort at all three lifelines has been unsuccessful. Of course, the clinician can decide to jump ahead to the fourth lifeline if warranted by the clinical condition or circumstances, such as, for example, a patient with an anticipated difficult airway and oxygen saturation of less than 90% in progressive deterioration, or after two unsuccessful attempts at two lifelines.The NAP4 report showed that the decision to effect CICO rescue was made when the patient was already severely hypoxic or close to death. Therefore, the decision to initiate the fourth lifeline should be based on failure of the “best effort” at securing a non-surgical airway, and should be taken before the patient becomes severely hypoxaemic. This would, at least in theory, ensure a better outcome (without the serious sequelae of oxygen deprivation) not only for the CICO rescue situation, but also for all lifelines.The “green zone”—a time for decisionsAs described above, the “green zone” is the area in which the airway has been secured using one of the four lifelines. The “green zone” is reached each time a rescue attempt succeeds in restoring alveolar oxygenation. Entry in the “green zone” can be confirmed by the presence of an ETCO2 waveform and/or increases in SpO2. A sustained SpO2 value achieved using apnoeic oxygenation techniques is not a “green zone”, because these manoeuvres cannot restore oxygenation in an already desaturated patient.<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows how the “green zone” extends from the base to the top of the funnel. This means that it can be entered at different levels of the Vortex, and indicates that the patient has not returned to baseline, spontaneous breathing, but that oxygenation has been restored by using one of the three non-surgical lifelines. The level at which the patient enters the green zone along the Vortex funnel (higher or lower) will be determined by the number of lifelines used up to that point. Of course, a lower level means that more lifelines with their optimisations have been used, and therefore reduces the number of options available before CICO rescue.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>However, there is also a green zone in the CICO rescue zone, since this lifeline also provides adequate alveolar oxygenation. Therefore, any point in the “green zone” is a temporary safety zone. The only permanent safety area is the return to spontaneous breathing.Each time the patient enters the “green zone”, they are no longer at risk of critical hypoxia. The green zone gives time to oxygenate the patient, gather resources and develop a new strategy. This is the equivalent of “stop and think” of the next strategy in the DAS algorithm.A new attempt at oxygenating the patient means a new safe apnoea time if further airway instrumentation is needed. Assembling resources included personnel (“ask for help”), equipment, and even changing location (for example, transfer from the emergency room to the operating theatre).The third lifeline should allow the patient to return to a safety zone:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">-maintain oxygenation with the last successful lifeline used, either to awaken the patient or proceed with surgery if urgent or indicated,</li><li class="elsevierStyleListItem" id="lsti0055">-convert the current airway to a more appropriate definitive airway while keeping the patient in the green zone, or</li><li class="elsevierStyleListItem" id="lsti0060">-replace the successful technique with another, more appropriate approach, providing that oxygenation can be maintained when abandoning the green zone and returning to the vortex.</li></ul>The different factors influence decision-making in the “green zone” can be grouped into 4 categories:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065">-Situational: includes both the emergency and the complexity of the situation in which the airway was secured.</li><li class="elsevierStyleListItem" id="lsti0070">-Airway: includes the stability of alveolar oxygenation, SpO2 level and variations, and the green zone entry level. The lower the green zone entry level, the more limited the options for restoring alveolar oxygenation before implementing CICO rescue.</li><li class="elsevierStyleListItem" id="lsti0075">-Patient: includes the risk of aspiration and the advisability of fasting, which can be influenced by the patient's level of consciousness and previous respiratory state, the use of drugs, and the indication for airway management.</li><li class="elsevierStyleListItem" id="lsti0080">-Clinician: involves the operator's experience with a specific technique. Any technique that the clinician does not fully master should be avoided.</li></ul>Whatever option is decided in the green zone, it must always include an alternative plan in case of failure; this plan can be either performing the remaining optimisation manoeuvres available, or CICO rescue.Limitations of the Vortex algorithmThe Vortex strategy was an individual effort to compensate for the limitations found in most algorithms, and to answer the need for dynamic strategies that address more than just the technical factors involved in successful intubation in a difficult airway situation.Algorithms are based on state-of-the-art scientific evidence. They are analysed and developed in consensus by a group of experts in a particular field. They are, therefore, structures designed and implemented in a specific geographical area, usually a country, although some are used worldwide and have been internationally validated. According to its authors, Vortex was designed to be a simple, global tool.None of the Vortex strategies have been included or described in any existing algorithms, all of which establish airway management strategies that range from least to most aggressive, depending on the patient's needs and oxygenation status. The aim of all algorithms, starting with the algorithm of the American Society of Anaesthesia, 1993,<a class="elsevierStyleCrossRef" href="#bib0575">57</a> is to achieve oxygenation as a point of balance from which to decide the next strategy. Once effective oxygenation has been achieved, they recommend evaluating whether to continue with that particular device or technique, change to a better option, awaken the patient, or resort to front of neck access.The recommendation to “stop and think what to do next” after restoration of oxygenation is implicit in all guidelines, and is in fact intrinsic to all humans, including physicians and anaesthesiologists.Although the introduction of ANTS in difficult airway management is an advantage of the Vortex strategy, it will also limit the introduction of this tool in resident training programmes (simulation-based training is only included in a few programmes for residents specialising in anaesthesiologists, emergency care or intensive care), and it is difficult to demonstrate with sufficient scientific evidence.How does Vortex contribute to airway management?The Vortex does not intend to replace, but rather complement, existing algorithms. In fact, it is more a cognitive aid than a true algorithm. The visual design of Vortex has some advantages over the conventional label and arrow structure of algorithms, insofar as it is simple to understand, and easy to remember and implement by all team members. These characteristics help reduce the team's “cognitive load” during a stressful situation such as an airway crisis. Vortex also facilitates effective communication, because it uses the same terms and concepts for the whole team, improves the decision-making process, can be used in any setting, keeps the team focussed on the task at hand.<a class="elsevierStyleCrossRef" href="#bib0580">58</a> Another advantage of the Vortex strategy is that it is applicable to any airway management situation.In conclusion, this novel approach to airway management using an algorithm based on cognitive aids and checklists may be an alternative tool for difficult airway management. It may be difficult to design studies to validate the Vortex, and its effectiveness will probably only become evident after widespread implementation.Conflict of interestsThe authors declare that they have no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1065096" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1013110" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1065095" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1013109" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Human factors and resource management during an airway crisis" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Why do difficult airway guidelines and algorithms fail?" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "What are cognitive aids? Are they useful in the management of an airway crisis?" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Anaesthesia non-technical skills (ANTS)" ] 9 => array:3 [ "identificador" => "sec0030" "titulo" => "The VÓRTEX algorithm" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "General description" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Pre-operative airway assessment and checklist" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Attempts and optimisations" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "“Best effort”: optimise for success or declare failure" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "CICO status: the fourth rescue technique" ] 5 => array:2 [ "identificador" => "sec0060" "titulo" => "The “green zone”—a time for decisions" ] ] ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Limitations of the Vortex algorithm" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "How does Vortex contribute to airway management?" ] 12 => array:2 [ "identificador" => "sec0071" "titulo" => "Conflict of interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-23" "fechaAceptado" => "2018-05-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1013110" "palabras" => array:4 [ 0 => "Difficult airway" 1 => "Airway management" 2 => "Algorithm" 3 => "Vortex approach" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1013109" "palabras" => array:4 [ 0 => "Vía aérea difícil" 1 => "Intubación difícil" 2 => "Algoritmos" 3 => "Vortex" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Airway management is an essential area in anaesthesia, and anaesthesiologists are considered the most expert professionals to manage airway tasks. However, complications related to inadequate airway management remain the most frequent cause of morbidity and mortality.Algorithmic strategy to solve difficulties fails, due to several factors related to its structure and clinical application.The Vortex Approach has emerged as a response to the limitations found in the algorithmic strategy of managing the difficult airway, by using a cognitive aid strategy to reduce cognitive load and fixation error. This new strategy may represent a solution to the elusive problem of the challenging airway and reduce the complications rate." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El aislamiento de la vía aérea es un área esencial en la anestesia. Los anestesiólogos se consideran los profesionales más expertos para resolver cualquier problema relacionado con una vía aérea difícil. Sin embargo, las complicaciones derivadas del manejo incorrecto de la vía aérea siguen siendo una de las causas más frecuentes de morbimortalidad asociada a la anestesia.La estrategia mediante algoritmos de tratamiento para resolver estas dificultades ha demostrado su fracaso debido a varios factores relacionados con su estructura y su aplicación clínica.El enfoque Vortex surge como una respuesta a las limitaciones encontradas en los algoritmos de manejo de una vía aérea difícil, utilizando una estrategia de ayudas para reducir la carga cognitiva y el error de fijación. Esta nueva estrategia puede representar una solución al problema de la dificultad de la vía aérea y, poder así, reducir la incidencia de complicaciones." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Charco-Mora P, Urtubia R, Reviriego-Agudo L. El modelo del Vórtex: una aproximación diferente a una vía aérea difícil. Rev Esp Anestesiol Reanim. 2018;65:385–393." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 337 "Ancho" => 750 "Tamanyo" => 31896 ] ] "descripcion" => array:1 [ "en" => "Vortex diagram with its three concentric rings. (A) frontal view, (B) lateral view (reproduced with permission from Nicholas Chrimes)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 317 "Ancho" => 750 "Tamanyo" => 41414 ] ] "descripcion" => array:1 [ "en" => "Possible sequence of the 3 non-surgical lifelines. Failure of all these will ultimately lead to the fourth level of rescue (reproduced with permission from Nicholas Chrimes)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 327 "Ancho" => 750 "Tamanyo" => 31952 ] ] "descripcion" => array:1 [ "en" => "The “green zone” on the outer ring and descending around the Vortex (reproduced with permission from Nicholas Chrimes)." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Facemask ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1 in 700 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SAD ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1 in 50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tracheal intubation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1 in 1500 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CICO status \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1 in 5000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Front of neck access \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">∼1 in 50,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1816166.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Failure rates of the four airway management approaches.<a class="elsevierStyleCrossRef" href="#bib0295">1</a>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:58 [ 0 => array:3 [ "identificador" => "bib0295" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Major complications of airway management in the UK: results of the fourth national audit project of the royal college of anaesthetists and the difficult airway society. 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The Vortex model: A different approach to the difficult airway

El modelo del Vórtex: una aproximación diferente a una vía aérea difícil

P. Charco-Moraa,c,

Corresponding author

pcharco@gmail.com

Corresponding author.

, R. Urtubiab, L. Reviriego-Agudoa

a Servicio de Anestesiología y Cuidados Críticos, Airway Management Teaching Center (FIDIVA), Universidad de Valencia, Hospital Clínico Universitario de Valencia, Valencia, Spain

b Servicio de Anestesiología, Clínica Vespucio, Santiago de Chile, Chile

c Vicepresidente de la Sección de Vía Aérea de la SEDAR, Spain

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        "titulo" => "El modelo del V&#243;rtex&#58; una aproximaci&#243;n diferente a una v&#237;a a&#233;rea dif&#237;cil"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Vortex diagram with its three concentric rings&#46; &#40;A&#41; frontal view&#44; &#40;B&#41; lateral view &#40;reproduced with permission from Nicholas Chrimes&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Successful airway management continues to be a fundamental skill for anaesthesiologists&#44; and these specialists are considered the best qualified to deal with difficult airway situations&#46; However&#44; problems stemming from poor airway management are still the most common cause of anaesthesia-related morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Management of a difficult airway is an example of a typical predictable clinical situation&#44; even though a difficult airway in a specific patient might not be foreseen&#46; All specialists involved in airway management know that an unanticipated difficult airway can be encountered at any time&#46; From the perspective of the patient &#40;and legal regulations&#41;&#44; a difficult airway can be considered a typical&#44; quantifiable and predictable complication&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">2</span></a> Similarly&#44; although infrequent in routine clinical practice&#44; surgical teams must be prepared to deal with and successfully resolve an airway crisis&#46; Inappropriate clinical management can worsen the situation and further restrict airway access&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">3</span></a> and ignorance and inadequate training contribute to the appearance of complications in up to 50&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Generally speaking&#44; there are 4 airway management approaches or strategies&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Facial approach</span></span>&#58; including the different oxygen therapy techniques &#40;ranging from common nasal cannula to high-flow systems&#41;&#44; manual ventilation with a face mask &#40;with adjuvants&#41;&#44; and different forms of ventilatory support using a facemask &#40;such as non-invasive mechanical ventilation&#44; Oxylator&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Transglottic approach</span></span>&#58; involves introducing a device into the trachea through the glottic opening&#46; Tracheal intubation is the gold standard for airway management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Supraglottic</span></span> &#40;or extraglottic&#41; <span class="elsevierStyleItalic"><span class="elsevierStyleBold">approach&#58;</span></span> involves the use of devices that seal the hypopharynx to deliver positive ventilation&#46; Some of these supraglottic devices include adjuvants to prevent gastric aspiration &#40;such as a gastric suction channel or drainage tube&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Infraglottic approach</span></span> &#40;front of neck access&#44; or FONA&#41;&#58; involves accessing the airway by means of an incision that&#44; due to the anatomy of the neck&#44; is usually made through the cricothyroid membrane &#40;cricothyroidotomy&#41;&#46;</p></li></ul></p><p id="par0040" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the failure rates of the different airway approaches&#46; It is important to note that the failure of 1 approach increases the possibility of failure of the next&#46; For example&#44; in an obese patient with positive predictors of difficult intubation&#44; the likelihood of ventilation difficulty is greater &#40;including ventilation through a supraglottic airway&#41;&#59; likewise&#44; percutaneous access to the airway can also be complicated&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Fortunately&#44; when 1 approach fails&#44; another can be tried&#44; and all can be used indistinctly to secure the airway and oxygenate the patient&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The number of anaesthesia-related complications has declined in recent decades&#46; Serious complications caused by hypoxaemia after intubation failure&#44; such as permanent neurological damage or death&#44;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">5&#44;6</span></a> have spurred researchers to develop new strategies and technologies to improve the standard of care and improve patient safety&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Efforts to improve airway management have led to the development of new technologies&#46; These include videolaryngoscopes &#40;with standard or difficult intubation blades&#41;&#44; various optical devices that incorporate the latest CMOS technology &#40;such as video stylets and video endoscopes&#41;&#44; as well as sophisticated&#44; state-of-the-art supraglottic devices&#44; even with passive oxygen insufflation&#46; To these can be added the latest techniques for denitrogenation or oxygenation through high flow nasal cannula &#40;THRIVE&#41;&#44; together with advanced systems for monitoring tissue oxygenation and different ventilatory methods &#40;neural control of ventilation&#41;&#46; Scientific societies&#44; for their part&#44; have developed their own treatment algorithms to implement all these new technologies in a structured manner&#44; based on expert consensus and the best available evidence&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Despite all these efforts&#44; incorrect management of an unanticipated difficult airway still results in serious complications&#46; Some of these problems stem from our approach to decision-making and our reaction to these highly stressful crisis scenarios&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Human factors and resource management during an airway crisis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Why are technical skills and algorithms insufficient to manage the most critical situations&#63; The fact is that stress impacts decision-making and performance&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">7</span></a> To explain this&#44; we must first define &#8220;the human factor&#8221; and &#8220;crisis resource management&#8221; &#40;CRM&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">There is currently no evidence to show the benefits of CRM tools in airway management&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">8</span></a> However&#44; CRM has been successfully tested in other areas where potentially high-risk situation can arise &#40;for example&#44; in the nuclear industry&#44; the aviation industry&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">9&#8211;11</span></a> and since the 90s&#44; when Gaba et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">12</span></a> adapted these new concepts to the field of anaesthesia &#40;Anaesthesia CRM&#41;&#44; they have been used in airway management&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The human factor is related to personal and team performance within a given system&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">13</span></a> This means that humans are fallible&#44; and our performance during a crisis is affected by personal and environmental factors&#44; external pressure&#44; and cognitive overload&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">14</span></a> The most important personal factors are&#58; fatigue&#44; lack of sleep&#44; emotional disturbance&#44; and inexperience&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">15&#44;16</span></a> The 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society reported that human factors contributed to adverse outcomes in 40&#37; of all cases involving serious or fatal injuries&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">1</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The concept of anaesthesia CRM refers to the non-technical skills required for effective teamwork in a crisis situation&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">17</span></a> Although Gaba described 15 key principles&#44; team performance during a crisis is determined by 4 decisive factors&#58; situational awareness&#44; decision-making&#44; task management&#44; and teamwork&#46; In an airway crisis&#44; cognitive overload often means that physicians &#8220;can&#8217;t see the forest for the trees&#8221;&#44; and become obsessed with a single task &#40;fixation error&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Therefore&#44; it is important to consider human factors and manage them appropriately&#44;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">18</span></a> since CRM training has been shown to improve performance<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">19</span></a> and with it&#44; patient outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Why do difficult airway guidelines and algorithms fail&#63;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Several different clinical guidelines for difficult airway management have been drawn up by the leading international scientific societies&#46; All are based on a critical review of the scientific literature&#44; together with consensus recommendations put forward by a panel of experts approved by the different national societies that regularly publish and update such guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">21&#8211;25</span></a> They provide a standardised approach to common clinical situations&#44; such as known and unanticipated difficult airway&#44; and a final solution for can&#8217;t intubate&#44; can&#8217;t oxygenate cases &#40;CICO&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">26</span></a> in addition to important recommendations for safe extubation&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">27&#44;28</span></a> For this purpose&#44; they recommend different strategies and intubation or ventilation devices&#44; depending on the experience or the state of the art&#46; However&#44; despite the widespread use of these algorithms&#44; there is no strong evidence to show the degree of benefit of any particular strategy&#44;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">29</span></a> although there is moderate evidence that the use of these guidelines improves airway management&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">30</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The NAP4 report is an in-depth analysis of the factors that contribute to poor airway outcomes&#44; and shows that these are clearly related to the patient&#39;s comorbidities or failure to predict the presence of a difficult airway&#46; The report also found other important positive factors&#44; such as good judgement&#44; planning&#44; the right equipment&#44; good communication within the team&#44; and training in airway management techniques&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Algorithms outline a sequence of steps to be taken when intubation fails&#44; always prioritising oxygenation and limiting the number of airway interventions to minimise trauma and complications&#46; However&#44; these recommendations often fail for various reasons&#58; clinical inertia&#44; the difficulties of implementing the recommended action within a particular the health system&#44; and limited access to the devices required&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">31&#44;32</span></a> Burgers et al&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">33</span></a> have shown that the main barriers to guideline implementation are the difficulties involved in learning new techniques or skills and in applying the rescue sequence in practice&#46; Leentjens and Burgers<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">34</span></a> conclude that successful implementation of such guidelines depends on creating a team with a shared vision&#44; where all members willingly follow the recommendations and accept them as a meaningful safety strategy&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Another reason for guideline inadequacy is their failure of guidelines to address two fundamental questions&#58; how should decisions be made in these highly stressful events&#63; And how the team be organised&#63; We know that algorithms are intended as teaching and learning tools&#44;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">35</span></a> and although they have also been useful in crisis management planning&#44; they are presented in a format that is of little use to a highly stressed team in the midst of an airway crisis&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">36</span></a> Only the latest DAS guidelines recommend that clinicians &#8220;stop and think&#8221; to avoid fixation errors in stressful situations&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Finally&#44; as the latest DAS guidelines acknowledge&#58; &#8220;The complexities of difficult airway management cannot be distilled into a single algorithm&#8221;&#46; The recommended actions are difficult to implement in a stressful&#44; emergency airway situation&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">This is why following guidelines and implementing algorithms do not in themselves guarantee a successful outcome or prevent serious complications&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">What are cognitive aids&#63; Are they useful in the management of an airway crisis&#63;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Some schematics or flowcharts have been used to help in the management of a series of anaesthesia-related emergencies&#44; such as anaphylactic shock&#44; malignant hyperthermia crisis&#44; etc&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">37</span></a> in the belief that they will help clinicians improve performance and successfully complete the task&#46; These strategies are called &#8220;cognitive aids&#44; or checklists&#44;&#8221; and are designed to guide stressed physicians through a sequence of complex steps and prevent them from skipping key actions&#46; Clinicians under stress are less capable of remembering lists of actions&#44; and are more likely to become fixated&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">38</span></a> Checklists and cognitive aids also help reduce errors and maximise effective teamwork&#46; For this to happen&#44; according to Marshall&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">39</span></a> a good cognitive aid must meet the following criteria&#58; &#40;1&#41; Its content must be derived from &#8220;best practice&#8221; guidelines or protocols&#59; &#40;2&#41; Its design should be appropriate for use in the context of the emergency situation&#59; &#40;3&#41; It should be familiar&#44; in a format that has been used in practice and training&#59; and &#40;4&#41; It should also assist other team members to perform their tasks in a coordinated manner&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Perhaps the best known crisis management tool&#44; and one that is easily remembered and implemented&#44; is the Advanced Cardiac Life Support &#40;ACLS&#41; protocol&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">40</span></a> This is a standardised tool that is applicable to all cardiac arrest situations&#44; and can be taught universally to all team members&#46; This tool has been enriched&#44; updated and validated by years of experience in its use worldwide&#46; Unlike the ACLS&#44; the development of an emergency airway management protocol involves unique challenges&#44; principally because the many different management options depend on the skill and preferences of the operator&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">41&#8211;43</span></a> Cognitive aids have been used in emergency scenarios&#44; and although they are widely believed to improve performance&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">44</span></a> this has never been proven&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">45</span></a> Marshall et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">46</span></a> performed a prospective study in airway crisis scenarios to evaluate the use of a visual algorithm in a simulated environment&#46; They found no significant differences in technical performance between the groups using and not using the aid&#44; but participants developed better non-technical skills&#46; More recently&#44; Long et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">47</span></a> evaluated the use of cognitive aids in the preparation of emergency paediatric airway equipment&#44; and concluded that its use reduces errors of omission&#46; Burden et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">48</span></a> meanwhile&#44; suggested that technical performance is improved when a team member reads out the contents of the checklist&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Anaesthesia non-technical skills &#40;ANTS&#41;</span><p id="par0130" class="elsevierStylePara elsevierViewall">The NAP4 report revealed some unexpected facts about the poor airway management practices of British anaesthesiologists&#44; and found evidence of poor or suboptimal performance in over 78&#37; of cases involving airway complications&#46; After analysing of the causes of this chilling finding&#44; the authors listed the main contributing factors as&#58; a poorly trained team&#44; poor communication within the team&#44; and poor clinical judgement in airway management&#46; Good training and communication would improve results&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">1</span></a> These factors are part of the so-called non-technical skills defined by Flin et al&#46; as &#8220;the cognitive&#44; social&#44; and personal resource skills that complement technical skills&#44; and contribute to safe and efficient task performance&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">17</span></a> These ANTS&#44; therefore&#44; define all actions performed by the anaesthesiologist in the operating theatre that are not related to their clinical experience or to the use of drugs and clinical devices&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">49</span></a> These include interpersonal communication&#44; teamwork and leadership skills&#44; together with cognitive aids to take stock of the situation and optimise decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">50</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Learning these non-technical skills can help improve routine clinical performance&#44; particularly in stressful situations that require the whole team to function correctly&#44; in terms of establishing the action plan&#44; following each step in the algorithm&#44; assigning tasks to each team member&#44; and correctly performing the procedures indicated&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">51&#8211;53</span></a> Both technical and ANTS can be learnt in a simulated environment that allows participants to perfect their skills&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">54&#44;55</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion&#44; there is no conclusive evidence that cognitive aids and non-technical skills are effective in anaesthesia&#44; mainly due to the limitations of research into these tools&#46; Therefore&#44; more studies are needed to determine the real contribution of these methods&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">The V&#211;RTEX algorithm</span><p id="par0145" class="elsevierStylePara elsevierViewall">The tragic case of Elaine Bromiley occurred in 2005&#46; Mrs&#46; Bromiley was scheduled for endoscopic sinus surgery and septoplasty under general anaesthesia&#46; Apart from slightly restricted cervical mobility&#44; there were no predictors of difficult intubation&#46; However&#44; after a series of ineffective manoeuvres to secure her airway&#44; Ms&#46; Bromiley entered can&#8217;t intubate &#8211; can&#8217;t oxygenate &#40;CICO&#41; status that could not be resolved&#44; and she eventually died&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">It was probably this unfortunate accident that prompted Nicholas Chrimes to develop a highly sensitive tool called Vortex<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">56</span></a> for early detection and resolution of problems stemming from poor airway management&#46; The tool was developed to prevent clinicians from become fixated on a particular technique or tool&#44; to improve decision-making&#44; and promote teamwork and is based on the four airway management approaches described above&#46; To simplify the protocol&#44; each strategy is called a &#8220;lifeline&#8221; in Vortex&#44; thus intentionally avoiding naming or recommending specific techniques or airway devices&#46; Vortex is intended to be easy to learn and use&#44; and is designed to simplify rescue during an airway crisis&#46; Following the algorithm&#44; clinicians can move from one lifeline to another&#44; based on&#44; but not limited to&#44; tracheal intubation as the standard technique&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">General description</span><p id="par0155" class="elsevierStylePara elsevierViewall">The Vortex &#40;or funnel-shaped diagram&#41; is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; It consists of three concentric rings representing three zones or layers&#58; the outer ring is the &#8220;green zone&#8221;&#44; and the centre is the &#8220;vortex&#8221;&#44; which includes the zone of &#8220;emergency front-of-neck access&#8221; or CICO rescue area&#46; The central blue ring &#40;vortex&#41; represents the 3 non-surgical lifelines&#58; facemask ventilation&#44; endotracheal tube&#44; and supraglottic airway&#46; The dark blue ring&#44; or emergency surgical airway&#44; is differentiated from the other rings to show the exceptional nature of the FONA approach&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Before the intervention&#44; the patient is breathing spontaneously and is in the outer &#8220;green zone&#8221;&#44; with normal alveolar oxygenation&#46; This is a &#8220;safety zone&#8221;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Once the intervention begins with anaesthesia induction&#44; the patient falls into the &#8220;vortex zone&#8221; where one of the three lifelines must restore and maintain alveolar oxygenation&#46; Airway management can begin with any lifeline and proceed through the subsequent lifelines in any order&#44; according to the plan of action and the objectives of the intervention &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Pre-operative airway assessment and checklist</span><p id="par0170" class="elsevierStylePara elsevierViewall">The Vortex algorithm also includes a pre-operative airway assessment and a safety checklist&#46; The pre-operative assessment is essential&#44; because it will alert the clinician to potential complications and allow him or her to draw up a contingency plan in the event of difficult intubation&#46; This airway assessment or airway prediction takes into account not only anatomical and physiological considerations&#44; but also situational and clinical elements &#40;human factors&#41; that may affect the procedure&#46; This should allow the clinician to evaluate the feasibility of securing the airway using each of the 4 lifelines&#44; and extend the safe apnoea time if any of the techniques should fail&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The checklist is the key to safe interventions&#44; proper teamwork&#44; and preventing hypoxia&#46; Checklists should be used in combination with the primary Vortex algorithm and the chosen airway device in the green zone&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Attempts and optimisations</span><p id="par0180" class="elsevierStylePara elsevierViewall">Each manipulation of the airway can cause trauma and tissue damage that can further hinder access&#44; and repeated unsuccessful attempts at intubation cause oedema and bleeding that can cause difficulties for ventilation and oxygenation&#46; This is why Vortex recommends making no more than three attempts with each lifeline&#46; In addition&#44; any repeated attempt with a lifeline must incorporate optimisations that have not previously been implemented in order to increase the chances of success&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The following is a list of some such optimisations&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">Change the position of the head&#47;neck&#47;larynx and of the device itself</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Use the adjuncts that are appropriate for each lifeline</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Changes size&#47;type of airway device</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Suction flow in hypopharynx&#47;oxygen&#44; and&#47;or control&#47;increase oxygen flow</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">Muscle tone&#44; administer or up-dose muscle relaxants&#46;</p></li></ul></p><p id="par0215" class="elsevierStylePara elsevierViewall">This means&#44; firstly&#44; that the clinician must decide which optimisations are most effective before each attempt&#44; and secondly&#44; not all three attempts allowed with each lifeline need to be exhausted if all the optimisations have been implemented&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">&#8220;Best effort&#8221;&#58; optimise for success or declare failure</span><p id="par0220" class="elsevierStylePara elsevierViewall">The completion of these 5 optimisation manoeuvres concludes the &#8220;best effort&#8221; with each lifeline &#40;not all 3 attempts are mandatory&#41;&#46; At least one of the attempts should be performed by the most experienced clinician&#46; Completion of the &#8220;best effort&#8221; in a given lifeline means that the optimisation options have been exhausted and&#44; if alveolar oxygenation has not been restored&#44; the attempt has failed and another approach is needed&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">When the &#8220;best effort&#8221; with all three lifelines has failed&#44; the clinician should prepare for the fourth and last lifeline &#40;rescue CICO&#41;&#44; even if oxygenation is still adequate&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">This structured definition of &#8220;best effort&#8221; with each lifeline is important from two perspectives&#58; it compels the clinician to use pre-defined optimisation manoeuvres&#44; and it is a decision-making tool that facilitates the transition from a failed life to another&#44; possibly successful&#44; approach&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">CICO status&#58; the fourth rescue technique</span><p id="par0235" class="elsevierStylePara elsevierViewall">CICO status is also a complementary tool with well-defined steps that prepare the team for rapid initiation of &#8220;CICO Rescue&#8221; once the best effort at all three lifelines has been unsuccessful&#46; Of course&#44; the clinician can decide to jump ahead to the fourth lifeline if warranted by the clinical condition or circumstances&#44; such as&#44; for example&#44; a patient with an anticipated difficult airway and oxygen saturation of less than 90&#37; in progressive deterioration&#44; or after two unsuccessful attempts at two lifelines&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The NAP4 report showed that the decision to effect CICO rescue was made when the patient was already severely hypoxic or close to death&#46; Therefore&#44; the decision to initiate the fourth lifeline should be based on failure of the &#8220;best effort&#8221; at securing a non-surgical airway&#44; and should be taken before the patient becomes severely hypoxaemic&#46; This would&#44; at least in theory&#44; ensure a better outcome &#40;without the serious sequelae of oxygen deprivation&#41; not only for the CICO rescue situation&#44; but also for all lifelines&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">The &#8220;green zone&#8221;&#8212;a time for decisions</span><p id="par0245" class="elsevierStylePara elsevierViewall">As described above&#44; the &#8220;green zone&#8221; is the area in which the airway has been secured using one of the four lifelines&#46; The &#8220;green zone&#8221; is reached each time a rescue attempt succeeds in restoring alveolar oxygenation&#46; Entry in the &#8220;green zone&#8221; can be confirmed by the presence of an ETCO2 waveform and&#47;or increases in SpO<span class="elsevierStyleInf">2</span>&#46; A sustained SpO<span class="elsevierStyleInf">2</span> value achieved using apnoeic oxygenation techniques is not a &#8220;green zone&#8221;&#44; because these manoeuvres cannot restore oxygenation in an already desaturated patient&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows how the &#8220;green zone&#8221; extends from the base to the top of the funnel&#46; This means that it can be entered at different levels of the Vortex&#44; and indicates that the patient has not returned to baseline&#44; spontaneous breathing&#44; but that oxygenation has been restored by using one of the three non-surgical lifelines&#46; The level at which the patient enters the green zone along the Vortex funnel &#40;higher or lower&#41; will be determined by the number of lifelines used up to that point&#46; Of course&#44; a lower level means that more lifelines with their optimisations have been used&#44; and therefore reduces the number of options available before CICO rescue&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0255" class="elsevierStylePara elsevierViewall">However&#44; there is also a green zone in the CICO rescue zone&#44; since this lifeline also provides adequate alveolar oxygenation&#46; Therefore&#44; any point in the &#8220;green zone&#8221; is a temporary safety zone&#46; The only permanent safety area is the return to spontaneous breathing&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Each time the patient enters the &#8220;green zone&#8221;&#44; they are no longer at risk of critical hypoxia&#46; The green zone gives time to oxygenate the patient&#44; gather resources and develop a new strategy&#46; This is the equivalent of &#8220;stop and think&#8221; of the next strategy in the DAS algorithm&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">A new attempt at oxygenating the patient means a new safe apnoea time if further airway instrumentation is needed&#46; Assembling resources included personnel &#40;&#8220;ask for help&#8221;&#41;&#44; equipment&#44; and even changing location &#40;for example&#44; transfer from the emergency room to the operating theatre&#41;&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">The third lifeline should allow the patient to return to a safety zone&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">maintain oxygenation with the last successful lifeline used&#44; either to awaken the patient or proceed with surgery if urgent or indicated&#44;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">convert the current airway to a more appropriate definitive airway while keeping the patient in the green zone&#44; or</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">replace the successful technique with another&#44; more appropriate approach&#44; providing that oxygenation can be maintained when abandoning the green zone and returning to the vortex&#46;</p></li></ul></p><p id="par0290" class="elsevierStylePara elsevierViewall">The different factors influence decision-making in the &#8220;green zone&#8221; can be grouped into 4 categories&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Situational&#58; includes both the emergency and the complexity of the situation in which the airway was secured&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0300" class="elsevierStylePara elsevierViewall">Airway&#58; includes the stability of alveolar oxygenation&#44; SpO<span class="elsevierStyleInf">2</span> level and variations&#44; and the green zone entry level&#46; The lower the green zone entry level&#44; the more limited the options for restoring alveolar oxygenation before implementing CICO rescue&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0305" class="elsevierStylePara elsevierViewall">Patient&#58; includes the risk of aspiration and the advisability of fasting&#44; which can be influenced by the patient&#39;s level of consciousness and previous respiratory state&#44; the use of drugs&#44; and the indication for airway management&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0310" class="elsevierStylePara elsevierViewall">Clinician&#58; involves the operator&#39;s experience with a specific technique&#46; Any technique that the clinician does not fully master should be avoided&#46;</p></li></ul></p><p id="par0315" class="elsevierStylePara elsevierViewall">Whatever option is decided in the green zone&#44; it must always include an alternative plan in case of failure&#59; this plan can be either performing the remaining optimisation manoeuvres available&#44; or CICO rescue&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Limitations of the Vortex algorithm</span><p id="par0320" class="elsevierStylePara elsevierViewall">The Vortex strategy was an individual effort to compensate for the limitations found in most algorithms&#44; and to answer the need for dynamic strategies that address more than just the technical factors involved in successful intubation in a difficult airway situation&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Algorithms are based on state-of-the-art scientific evidence&#46; They are analysed and developed in consensus by a group of experts in a particular field&#46; They are&#44; therefore&#44; structures designed and implemented in a specific geographical area&#44; usually a country&#44; although some are used worldwide and have been internationally validated&#46; According to its authors&#44; Vortex was designed to be a simple&#44; global tool&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">None of the Vortex strategies have been included or described in any existing algorithms&#44; all of which establish airway management strategies that range from least to most aggressive&#44; depending on the patient&#39;s needs and oxygenation status&#46; The aim of all algorithms&#44; starting with the algorithm of the American Society of Anaesthesia&#44; 1993&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">57</span></a> is to achieve oxygenation as a point of balance from which to decide the next strategy&#46; Once effective oxygenation has been achieved&#44; they recommend evaluating whether to continue with that particular device or technique&#44; change to a better option&#44; awaken the patient&#44; or resort to front of neck access&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">The recommendation to &#8220;stop and think what to do next&#8221; after restoration of oxygenation is implicit in all guidelines&#44; and is in fact intrinsic to all humans&#44; including physicians and anaesthesiologists&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Although the introduction of ANTS in difficult airway management is an advantage of the Vortex strategy&#44; it will also limit the introduction of this tool in resident training programmes &#40;simulation-based training is only included in a few programmes for residents specialising in anaesthesiologists&#44; emergency care or intensive care&#41;&#44; and it is difficult to demonstrate with sufficient scientific evidence&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">How does Vortex contribute to airway management&#63;</span><p id="par0345" class="elsevierStylePara elsevierViewall">The Vortex does not intend to replace&#44; but rather complement&#44; existing algorithms&#46; In fact&#44; it is more a cognitive aid than a true algorithm&#46; The visual design of Vortex has some advantages over the conventional label and arrow structure of algorithms&#44; insofar as it is simple to understand&#44; and easy to remember and implement by all team members&#46; These characteristics help reduce the team&#39;s &#8220;cognitive load&#8221; during a stressful situation such as an airway crisis&#46; Vortex also facilitates effective communication&#44; because it uses the same terms and concepts for the whole team&#44; improves the decision-making process&#44; can be used in any setting&#44; keeps the team focussed on the task at hand&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">58</span></a> Another advantage of the Vortex strategy is that it is applicable to any airway management situation&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">In conclusion&#44; this novel approach to airway management using an algorithm based on cognitive aids and checklists may be an alternative tool for difficult airway management&#46; It may be difficult to design studies to validate the Vortex&#44; and its effectiveness will probably only become evident after widespread implementation&#46;</p></span><span id="sec0071" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0091">Conflict of interests</span><p id="par0341" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests&#46;</p></span></span>"
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          "identificador" => "xres1065096"
          "titulo" => "Abstract"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Human factors and resource management during an airway crisis"
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        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Why do difficult airway guidelines and algorithms fail&#63;"
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          "identificador" => "sec0020"
          "titulo" => "What are cognitive aids&#63; Are they useful in the management of an airway crisis&#63;"
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          "identificador" => "sec0025"
          "titulo" => "Anaesthesia non-technical skills &#40;ANTS&#41;"
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          "titulo" => "The V&#211;RTEX algorithm"
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              "titulo" => "General description"
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              "titulo" => "Pre-operative airway assessment and checklist"
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              "identificador" => "sec0045"
              "titulo" => "Attempts and optimisations"
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            3 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "&#8220;Best effort&#8221;&#58; optimise for success or declare failure"
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            4 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "CICO status&#58; the fourth rescue technique"
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              "identificador" => "sec0060"
              "titulo" => "The &#8220;green zone&#8221;&#8212;a time for decisions"
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          "identificador" => "sec0065"
          "titulo" => "Limitations of the Vortex algorithm"
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          "identificador" => "sec0070"
          "titulo" => "How does Vortex contribute to airway management&#63;"
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          "titulo" => "Conflict of interests"
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          "clase" => "keyword"
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            0 => "Difficult airway"
            1 => "Airway management"
            2 => "Algorithm"
            3 => "Vortex approach"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1013109"
          "palabras" => array:4 [
            0 => "V&#237;a a&#233;rea dif&#237;cil"
            1 => "Intubaci&#243;n dif&#237;cil"
            2 => "Algoritmos"
            3 => "Vortex"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Airway management is an essential area in anaesthesia&#44; and anaesthesiologists are considered the most expert professionals to manage airway tasks&#46; However&#44; complications related to inadequate airway management remain the most frequent cause of morbidity and mortality&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Algorithmic strategy to solve difficulties fails&#44; due to several factors related to its structure and clinical application&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The Vortex Approach has emerged as a response to the limitations found in the algorithmic strategy of managing the difficult airway&#44; by using a cognitive aid strategy to reduce cognitive load and fixation error&#46; This new strategy may represent a solution to the elusive problem of the challenging airway and reduce the complications rate&#46;</p></span>"
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      "es" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El aislamiento de la v&#237;a a&#233;rea es un &#225;rea esencial en la anestesia&#46; Los anestesi&#243;logos se consideran los profesionales m&#225;s expertos para resolver cualquier problema relacionado con una v&#237;a a&#233;rea dif&#237;cil&#46; Sin embargo&#44; las complicaciones derivadas del manejo incorrecto de la v&#237;a a&#233;rea siguen siendo una de las causas m&#225;s frecuentes de morbimortalidad asociada a la anestesia&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La estrategia mediante algoritmos de tratamiento para resolver estas dificultades ha demostrado su fracaso debido a varios factores relacionados con su estructura y su aplicaci&#243;n cl&#237;nica&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El enfoque Vortex surge como una respuesta a las limitaciones encontradas en los algoritmos de manejo de una v&#237;a a&#233;rea dif&#237;cil&#44; utilizando una estrategia de ayudas para reducir la carga cognitiva y el error de fijaci&#243;n&#46; Esta nueva estrategia puede representar una soluci&#243;n al problema de la dificultad de la v&#237;a a&#233;rea y&#44; poder as&#237;&#44; reducir la incidencia de complicaciones&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Charco-Mora P&#44; Urtubia R&#44; Reviriego-Agudo L&#46; El modelo del V&#243;rtex&#58; una aproximaci&#243;n diferente a una v&#237;a a&#233;rea dif&#237;cil&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;385&#8211;393&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Vortex diagram with its three concentric rings&#46; &#40;A&#41; frontal view&#44; &#40;B&#41; lateral view &#40;reproduced with permission from Nicholas Chrimes&#41;&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Possible sequence of the 3 non-surgical lifelines&#46; Failure of all these will ultimately lead to the fourth level of rescue &#40;reproduced with permission from Nicholas Chrimes&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The &#8220;green zone&#8221; on the outer ring and descending around the Vortex &#40;reproduced with permission from Nicholas Chrimes&#41;&#46;</p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Facemask ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;1 in 700&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SAD ventilation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;1 in 50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tracheal intubation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;1 in 1500&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;1 in 5000&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Failure rates of the four airway management approaches&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">1</span></a></p>"
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          "identificador" => "bibs0015"
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Major complications of airway management in the UK&#58; results of the fourth national audit project of the royal college of anaesthetists and the difficult airway society&#46; Part 1&#58; Anaesthesia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T&#46;M&#46; Cook"
                            1 => "N&#46; Woodall"
                            2 => "C&#46; Frerk"
                          ]
                        ]
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                    0 => array:2 [
                      "doi" => "10.1093/bja/aer058"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Anaesth"
                        "fecha" => "2011"
                        "volumen" => "106"
                        "paginaInicial" => "617"
                        "paginaFinal" => "631"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21447488"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            1 => array:3 [
              "identificador" => "bib0300"
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