Introduction
This statement was planned on 11 March 2020 to provide clinical guidance and aid staff preparation for the coronavirus disease 2019 (COVID‐19) pandemic in Australia and New Zealand. It has been widely endorsed by relevant specialty colleges and societies.
Main recommendations
Generic guidelines exist for the intubation of different patient groups, as do resources to facilitate airway rescue and transition to the “can't intubate, can't oxygenate” scenario. They should be followed where they do not contradict our specific recommendations for the COVID‐19 patient group.
Consideration should be given to using a checklist that has been specifically modified for the COVID‐19 patient group.
Early intubation should be considered to prevent the additional risk to staff of emergency intubation and to avoid prolonged use of high flow nasal oxygen or non‐invasive ventilation.
Significant institutional preparation is required to optimise staff and patient safety in preparing for the airway management of the COVID‐19 patient group.
The principles for airway management should be the same for all patients with COVID‐19 (asymptomatic, mild or critically unwell).
Safe, simple, familiar, reliable and robust practices should be adopted for all episodes of airway management for patients with COVID‐19.
Changes in management as a result of this statement
Airway clinicians in Australia and New Zealand should now already be involved in regular intensive training for the airway management of the COVID‐19 patient group. This training should focus on the principles of early intervention, meticulous planning, vigilant infection control, efficient processes, clear communication and standardised practice.
Factors influencing performance during emergency airway management can be broadly divided into issues with preparation and those with implementation. Effective design of resources that provide guidance on management requires consideration of the context in which they are to be used. Many of the major airway guidelines do not specify whether they are intended to be used during preparation or implementation and may not take the context for use into account in their design. This can produce tools which may be not only ineffective but actively disruptive to team function in an emergency. The Vortex is a novel, simple, and predominantly visually based cognitive aid, which has been specifically designed to be used in real time during airway emergencies to support team function and target recognized failings in airway crisis management. Unlike the major algorithms, which are context specific, the Vortex is flexible enough for the same tool to be applied to any circumstance in which airway management takes place, independent of context, patient type, or the intended airway device. This makes the same tool suitable for use by emergency physicians, intensivists, paramedical staff, and anaesthetists. The Vortex contains many of the recognized features of an ideal cognitive tool and may be effective in reducing implementation errors in emergency airway management. Experimental evidence is required to establish this.
Emergency cricothyroidotomy is a temporary, life-saving procedure, indicated immediately when the airway is obstructed and oxygen delivery is unable to be restored by other means. It is therefore the final step in the guidelines for the management of difficult airways, reserved for can't intubate, can't oxygenate (CICO) emergencies. Debate over whether use of a cannula or scalpel provides the best technique for emergency front-of-neck access by anaesthetists in these circumstances must logically consider the likelihood of technical success of each of these methods. The effectiveness of either technique as a rescue strategy is also dependent, however, on a clinician's willingness to implement it.The recently published 2015 Guidelines of the Difficult Airway Society (DAS) endorse scalpel cricothyroidotomy as the sole method for emergency front-of-neck access. 1 This editorial addresses the possible implications of this decision on the psychological preparedness of clinicians to undertake the transition to emergency surgical airway. The updated DAS Guidelines acknowledge that much of the data for this recommendation comes from sources which cannot be translated directly to inhospital anaesthetic practice. 1 The lack of clear technical superiority of one technique over the other, combined with the knowledge that the decision to perform front-of-neck access is frequently undertaken too late or not at all, 2-4 further increases the weight that must be given to the impact that these techniques might have on a clinician's 'willingness to act' in the CICO scenario.Appropriate decision-making, availability of equipment, technical ability, and human factors considerations, all supported by regular training, are essential for successful performance of front-of-neck access techniques when a CICO event occurs. As such, the following considerations potentially make a cannula-based technique more suitable than the scalpel-based technique for the anaesthetist in their initial attempt at front-of-neck access.
The impact of human factors on clinical performance during airway emergencies is well recognised [1][2][3][4][5]. Although this includes 'teamwork skills' such as leadership, role allocation and communication, the scope of human factors is much broader than this. As the scientific discipline concerned with understanding and optimising the interactions between humans and other elements of a system, human factors involves considering the impact of aspects of the individual, environment, processes and culture on human performance [6]. The availability and presentation of airway equipment is a key component of the clinical environment in relation to airway management [7].
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