The VORTEX- approach to airway- management

Parts of this presentation about the VORTEX- approach were presented in October 2014 at the DevelopingEM- conference at Salvador de Bahia, Brasil.

The presentation is about airway-management, especially about a new kognitive aid for airway- management. The VORTEX- approach was intended by Nicholas Chrimes and Peter Fritz from Melburne in Australia and first published in the internet in 2013.
The beauty of the vortex is it‘s universality and it‘s ease to remember, because it‘s not a flowchart or an algorithm but a three-dimensional- approach to airway-management. You will understand later.

First of all I want to point out the goal of airway-management. During the last century the main effort in AW Management was put on avoiding an aspiration. Mendelson described 1946 obstetrical cases with a respiratory syndrome which showed a dramatic onset of cyanosis, dyspnea and tachycardia. This started two to five hours after aspiration and lead to shock. The mortality of the Mendelson‘s syndrom was up to 60% and led to the focus on avoiding an aspiration in relations to anesthesia. The techniques for rapid sequence induction inproved and the therapy for servere lung injuries improved too. One of the lates publication concerning ARDS of Guérin et al. in the New Engl J Med from 2013 showed a reduction of Mortality in servere ARDS down to 23% while Prone Positioning in the ICU. Another study of Sakles et al., also from 2013, analysed the Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. They found an aspiration rate in non-fasted emergency patient of around 1 to 6 %. They analyzed also the incidence of Desaturation. In 9-37% of these rapid sequence inductions was a significant desaturation detected. As everybody knows can hypoxia led to servere brain damage in a short period of time. Other studies showed also, that the priorisation on avoiding aspiration can led to desaturation with harm for the patient. The priority was put on maintaining alveolar oxygenation while securing the airway. Desaturation can occure quickly after anesthesia induction and apnea. Even when adequate preoxygenated the Saturation starts to drop after 2 to 5 minutes. The former imperative for non-ventilation during RSI can led to Hypoxia. This is depending on the conditions of the patient and the duration until a alveolar oxygenation is established. Especially obese patients, ill patients and children are at risk for early desaturation. In respect for this data the recommendations for RSI for children were adapted in 2006 in Germany. Pressure controlled (bag mask) ventilation is now indicated until the conditions for endotrachel intubations are optimized. Oxygenation has the highest priority during RSI.

The second important issue I want to highlight are the lessons learned by the NAP4 publication in 2011 in the British Journal of Anesthesia. A national audit was published which analyzed the death by airway problems in Great Britain. Apart of many other reasons for these dead patients, there was a failure to plan for failure detected. At a certain point there was a kind of mental blockade causing a leak of progress in the proceedings for difficult airway management. Even if there are lots of difficult airway flowchats published, many are to complicated to remember under stress or to specialized for anesthesia purpose. So some providers stuck in an unsuccessul activity without beeing able to escalate their airway-management. To have a simple and memorable cognitive tool in mind is a big advantage in situations when action on brainstem level is needed.

And third of all I want you to remember 5 possible accesses to alveolar oxygenation. There we have three non-surgical airway techniques like an extraglottic airway which means to provide oxygen with a face mask, the supraglottic airway in terms of placement of a laryngeal mask in the hypopharynx and the transglottic airway for the endotracheal tube. Furthermore we can achive the airway via a surgical procedure. There are two possibilities for an emergency surgical airway like a cricoidotomy or a tracheotomy.

Now I want to explain the concept of the vortex approach.
It‘s not that complicated. As you can see: The vortex is build three dimensional like a cone with a green zone at the top and a blue funnel which is open at the bottom end. The green zone symbolizes the situation with an oxygenated patient with access to alveolar oxygenation. The primary goal is to reach the green zone. The blue funnel symbolizes apnea and the need to establish alveolar oxygenation again.
We leave the green zone through induction of anesthesia with apnea or by desaturation of a respiratory compromised patient. The VORTEX is constructed three- dimensional. That allows at the beginning of the airway- management to choose between one of the three non-surgical airway- techniques. The airway provider can decide whether to use a face- mask, a laryngeal mask or the endotracheal tube. Which tool is approriate is depending on the circumstances of the airway-management. The VORTEX approach gives you the choise to choose the right tool for the right moment. But it allows only a maximum of three attempts at each non-surgical airway-technique. In case the green zone is not reached again, the VORTEX suggestes to progress to an emergency surgical airway. One of the three attempts on each airway-technique should be done by the most experienced clinican available. More than three attemps on each airway- technique are not indicated.
The primary goal is to provide alveolar oxygenation. The second goal is to maintain airway patenty.

The vortex-approach recommends fife optimisation strategies to apply on every attempt, which are Manipulation, Adjunct, Size, Sucction and Muscle tone.
For the practical approach, it means on every attempt to manipulate the position of the head, neck, larynx and or the device. Then to use an adjunct like an orophayngeal and/or nasopharyngeal airway- device. You shoud consider to change the size of the airway- device and try to to succ secretion out of the pharynx for a better view. And last but not least it is to check the pharyngeal muscle tone. Then you can decide whether to wake up the patient or to deepen relaxation and anesthesia.
You see the numbers 3 and 5 take a great place in the VORTEX- approach. Three attempts on three non-surgical airway techniques. Fife optimization strategies and 5 airway-levels. It is wise to go through these points for each try.

To confirm alveolar oxygenation endtidal carbon dioxide should be messured. As there is almost no carbon dioxide in the air the detection of etCO2 signals gas exchange with the lungs. And where gas comes out, logically gas went in, too. There you have an indirect prove of alveolar oxygenation. To wait for a change of saturation during airway- mangement takes to long and is too uncertain to trust. Furthermore endtidal CO2 gives information not only about ventilation but also lung- perfusion, cardiac output and the metabolism.

The Vortex-approach is an universal cognitive aid to airway-management. It does not exclude any airway-device. When the green zone is established, the right tool for a difficult airway can be choosen. When the aim was to perform endotracheal intubation and it was not reached after three attempts, but a laryngeal mask was established, then there is time to plan for the next step. If the tools are available and a trained clinician is on site, every device from any difficult-airway algorithm can be put in place. The vortex approach does not supply a solution for every difficult airway problem. It is not a flow-chart or an algorithm. The Vortex approach is a cognitive aid to focus on goals like alveolar oxygenation and progression in airway-management. It gives practical support with optimisation strategies and limits the trys on each airway-technique. That supports the provider to go ahead even up to an energency surgical airway.

But what shall we do when it comes to perform an emergency surgical airway? When we did three atempts on each non-surgical-airway-technique but we didn’t reach the green zone, when there is no alveolar oxygen delivery? How shall we perform the surgical airway?
What does Airway- societies say? I didn‘t find any clear recommendations when and how to perform an emergency surgical airway.
Don’t you think it’s allready to late when it comes to hypoxia with bradycardia in a difficult airway- situation ? Do we still have the rescources and time to safe the patients life?

The VORTEX- approach provides a clear strategy when to perform an emergency surgical airway. It does not recommend to wait and try until the saturation dropps. If there were up to three attempts on each non-surgical airway-technique performed with at least one optimal attempt and no alveolar oxygen delivery was detected, an emergency surgical airway is indicated.
To lower the barriers to perform finaly a surgical airway, the preparation for the surgical procedure should be done during the airway-managment and with every airway technique, which is faded, the preparation to perform an emergency surgical airway should be escalated.

But which technique should be used? The data are not consistent and there are suggestions to start with a needle cricoidotomy and progress to a surgical emergency airway in case of failure.
I recommend the technique you are trained in and you are comfortable with. Do you have a surgical background? Take the blade. Are you experienced with Seldinger- Technique? Use the MELKER set. And so on… Most important is JUST DO IT. And therefore is the VORTEX approach.
It’s an universal and easy to remember cognitive aid, which guides you to the next step, even if it is to perform an emergency surgical airway.

So, don’t forget to plan for Failure,
Use all 5 airway techniques availlable
Don’t stand still like a rabbit in front of a snake and take the next step in airway-managment.
And at least I whish you NO-DESATURATION for your patients

references
http://www.vortexapproach.com/Vortex_Approach/Vortex.html
*American Society of Anesthesiologists: Practice guidelines for management of the difficult airway: Anesthesiology 2003; 98:1269–1277. update: Anesthesiology 2013; 118:251–70
J. J. Henderson et al. Difficult Airway Society guidelines for management of the unanticipated difficult intubation http://www.das.uk.com
A. Timmermann et al. Handlungsempfehlung für das präklinische Atemwegsmanagement* Anästh Intensivmed 2012;53:294-308
T. M. Cook 1 et al. On behalf of the Fourth National Audit Project. British Journal of Anaesthesia 106 (5): 632–42 (2011)
Christopher T. et al. The Success of Emergency Endotracheal Intubation in Trauma Patients: A 10-Year Experience at a Major Adult Trauma Referral Center. Anesth Analg 2009;109:866–72
Chesters A. et al. Prehospital anaesthesia performed in a rural and suburban air ambulance service staffed by a physician and paramedic: a 16-month review of practice. Emerg Med J. 2014 Jan;31(1):65-8.
Ellis DY et al. Cricoid pressure in emergency department rapid sequence tracheal intubations. Ann Emerg Med 2007;50:653-65
Bernhard M et al. Developing the skill of endotracheal intubation: implication for emergency medicine. Acta AnaeScand 2012;56:164-171
Alexander F. Arriaga et al. Simulation-Based Trial of Surgical-Crisis Checklists NEJM 2013; 368:246-253
Müller JU et al. The use of the laryngeal tube disposable by paramedics during out-of-hospital cardiac arrest: a prospectively observational study Emerg Med J. 2013 Dec;30(12):1012-6.
Schalk R. et al. Disposable laryngeal tube suction: standard insertion technique versus two modified insertion techniques for patients with a simulated difficult airway. Resuscitation. 2011 Feb;82(2):199-202
John C. Sakles et al. The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department. Academic Emergency Medicine Volume 20, Issue 1, pages 71–78, January 2013
Guérin et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome (PROSEVA). New Engl J Med 2013;epublished May 20th